MENTALLY    DEFICIENT   CHILDREN 


.MENTALLY    DEFICIENT 
CHILDREN 

THEIR  TREATMENT  AND 
TRAINING 


G.  E.  SHUTTLEWORTH,  B.A.,  M.D.,  &c. 

FELLOW    OF    KING'S    COLLEGE,    LONDON; 

HON.    CONSULTING    PHYSICIAN    (FORMERLY    MEDICAL   SUPERINTENDENT),    ROYAL 

ALBERT   INSTITUTION,    LANCASTER,    FOR   THE    FEEBLE-MINDED    OF    THE    NORTHERN 

COUNTIES  ; 

"SPECIAL  SCHOOLS"  MEDICAL  OFFICER,  WILLESDEN  EDUCATION  COMMITTEE; 

FORMERLY  ASSISTANT  MEDICAL  OFFICER,   ROYAL  EARLSWOOD  INSTITUTION   FOR 

MENTAL  DEFECTIVES  ; 

MEDICAL   EXAMINER   OF    DEFECTIVE   CHILDREN   TO   THE   (LATE)   SCHOOL 

BOARD    FOR   LONDON  J 
AND  MEDICAL   EXPERT,    M.    A.  B,  INSTITUTION    FOR   IMPROVABLE    IMBECILES,    BALING 

AND 

W.  A.  POTTS,  M.A.,  M.D.,  &c. 

MEDICAL   OFFICER    TO   THE   BIRMINGHAM    COMMITTEE    FOR   THE    CARE   OF   THE 

MENTALLY   DEFECTIVE  ; 
LATE   MEDICAL   INVESTIGATOR   TO   THE   ROYAL   COMMISSION    ON   THE   CARE   AND 

CONTROL   OF    THE   FEEBLE-MINDED, 

AND    CHAIRMAN   OF  THE  AFTER-CARE  (SPECIAL  SCHOOLS)  COMMITTEE,  BIRMINGHAM 

FORMERLY   RESIDENT    MEDICAL    OFFICER,    YORKSHIRE   EAST   RIDING 

LUNATIC   ASYLUM 


FOURTH    EDITION 


PHILADELPHIA 
P.    BLAKISTON'S   SON    &    CO. 

1012   WALNUT   STREET 
1916 


H 


i    PRINTED  IN  ENGLAND. 


TO    THE    MEMORY    OF 
THE    TRULY    ILLUSTRIOUS 

EDOUARD    SEGUIN,    M.D. 

WHO    FOR    FORTY-TWO    YEARS, 
BOTH    IN    THE    OLD    WORLD    AND    THE    NEW, 

PRACTICALLY    AND    WITH    HIS    PEN 
LABOURED    TO    IMPROVE    THE    CONDITION    OF 

MENTALLY    DEFICIENT    CHILDREN 

BY    THE    APPLICATION    OF 

PHYSIOLOGY     TO     EDUCATION; 

THIS    BOOK    IS    INSCRIBED. 

"  He  loved  others  better  than  himself." 


372363 


PREFACE  TO  FOURTH  EDITION 

THE  Third  Edition  having  some  time  ago  been  ex- 
hausted, and  frequent  inquiries  for  copies  continuing, 
the  authors  have  gladly  availed  themselves  of  the 
opportunity  of  thoroughly  revising  this  work  in  the 
preparation  of  a  new  edition.  During  the  last  five 
years  increasing  public  attention  has  been  given  to 
the  Mentally  Defective  Class,  culminating  in  the  pas- 
sage through  the  Legislature  of  the  Mental  Deficiency 
Acts  for  England  and  Wales,  and  for  Scotland,  re- 
spectively. An  Act  amending  the  "  Elementary 
Education  (Defective  and  Epileptic  Children)  Act"  of 
1899  has  also  been  passed.  Consequent  administra- 
tive and  educational  changes  have  had  to  be  set  forth, 
involving  some  condensation  of  matter  in  the  last 
edition.  Much,  indeed,  has  been  rearranged  and  re- 
written. Chapter  VI.,  dealing  with  the  mental 
troubles  of  youth,  has  been  added,  and  the  illustra- 
tions have  been  rearranged  and  supplemented  by 
one  or  two  fresh  plates.  Thanks  are  due  to  several 
professional  friends  for  the  loan  of  blocks,  and  to  Miss 
Ethel  Dixon  for  kind  assistance  in  preparing  the 
index. 

It  is  hoped  that  the  present  edition  may  enjoy  a 


viii          PREFACE  TO  FOURTH  EDITION 

share  of  the  favour  which  has  been  so  liberally  ac- 
corded to  its  predecessors;  and  it  is  encouraging  to 
its  authors  that  not  only  a  French  version  of  the  work 
has  been  published,*  but  that  permission  to  trans- 
late it  into  Japanese  has  recently  been  requested. 


G.  E.  S. 
W.  A.  P. 


May,  1916. 


*  "  Les  Enfants  Anormaux  au  point  de  vue  mental."  J. 
Lebegue  et  Cie,  Libraires-]±diteurs,  46,  Rue  de  la  Madeleine, 
Bruxelles.  Traduite  par  le  Docteur  Ley.  1904. 


PREFACE  TO   FIRST   EDITION 

IN  offering  this  little  Manual  to  the  Medical  Profes- 
sion, and  to  the  increasing  number  of  the  Public  who 
take  an  interest  in  the  special  education  of  mentally 
deficient  children,  the  author  trusts  that  the  experi- 
ence acquired  by  the  proverbial  "  quarter-of-a-cen- 
tury's  "  successive  residence  in  two  of  the  largest 
Training  Institutions  for  Imbeciles  may  aid  him  in 
setting  forth  both  the  salient  peculiarities  of  the  class 
and  the  ameliorative  measures  found  most  useful. 
He  does  not  profess  to  bring  forward  much  that  is 
new,  but  rather  to  collect  and  mould  into  book  form 
various  papers  published  by  him  during  the  last 
twenty  years  in  Medical  Journals  and  the  Proceedings 
of  Societies. 

In  the  present  volume,  the  pathology  of  the  subject 
is  only  touched  on  to  supply  a  few  practical  hints 
which  may  be  of  service  to  the  medical  man  in  his 
diagnosis,  prognosis,  and  recommendations,  when 
consulted  in  the  case  of  a  mentally  feeble  or  deficient 
child.  Though  his  standpoint  is  that  of  the  physician, 
and  not  of  the  teacher,  the  author  hopes  that  his 
observations  upon  special  educational  methods,  based 
as  they  are  upon  physiological  principles,  may  not  be 


x  PREFACE  TO  FIRST  EDITION 

without  value  to  those  engaged  in  the  practical  work 
of  instruction.  For  the  successful  training  of  the 
mentally  deficient  child,  the  physician  and  the  teacher 
must  go  hand  in  hand ;  and  it  will  be  a  satisfaction 
to  the  author  if  in  some  slight  degree  this  book 
realizes  the  aspirations  of  Seguin,  who  was  both. 
"  Let  us  physicians,"  he  says  (in  the  course  of  an 
address  to  a  New  York  Medical  society),  "  help  to 
build  the  programme  of  physiological  education 
already  sketched  in  the  School  for  Idiots.  .  .  .  The 
demonstration  therein  given  is  that  the  physiological 
education  of  the  senses  is  the  royal  road  to  the  educa- 
tion of  the  intellect;  experience,  not  memory,  the 
mother  of  ideas." 

G.  E.  S. 

May,  1895. 


/ 

'  r 


CONTENTS 
CHAPTER  I 

HISTORICAL  RETROSPECT 

PAGE 

The  work  of  Seguin,  Saegert,  Guggenbiihl,  Itard,  Voisin, 
and  Esquirol.  The  writings  of  Twining,  Gaskell,  and 
Conolly  lead  to  the  establishment  in  Great  Britain 
of  Training  Schools  for  mentally  deficient  children. 
Recent  development  of  Institutions  for  Defectives. 
Early  scientific  investigations.  Swiss  statistics  -  I 

CHAPTER  II 
DEFECTIVE  AND  EPILEPTIC  CHILDREN 

Official  investigations  by  English  Education  Department 
as  to  above,  and  consequent  legislation.  Special 
Schools:  their  merits  and  shortcomings.  Royal 
Commission  on  the  Care  and  Control  of  the  Feeble- 
minded: their  Report  and  Recommendations. 
Mental  Deficiency  Acts  (England  and  Scotland) : 
their  leading  provisions.  Regulations  issued  by 
Home  Secretary  -  18 

CHAPTER  III 
SPECIAL  INSTRUCTION 

Definitions  in  Mental  Deficiency  Act,  and  in  the  Educa- 
tion Acts  (1899  and  1914).     Special  Schools  on  the 
Continent    and    in    America.     Their    arrangements 
and  developments  in  England.     Illustrative  cases     -     35 
xi 


xii  CONTENTS 


CHAPTER  IV 

PATHOLOGICAL  CLASSIFICATION  OF  FORMS 
OF  MENTAL  DEFICIENCY 

PAGE 

General  pathology.  Primary  and  secondary  amentia. 
Microscopic  and  macroscopic  appearances.  Primary 
Types. — Defects  of  the  corpus  callosum  and  partial 
atrophies.  Word -deaf  ness  and  word -blind  ness. 
Mind-blindness.  Microcephalus.  Hydrocephalus. 
Hypertrophic  cases.  "  Mongol "  type.  Neurotic 
(scaphocephalic).  Simple  congenital.  Developmental 
Types. — Epiloia,  or  tuberous  sclerosis :  Eclampsic. 
Epileptic.  Syphilitic  (juvenile  general  paralysis  of 
the  insane).  Birth-palsies,  etc.  Secondary  Types.— 
Traumatic.  Post-febrile  (oxycephaly) .  Emotional. 
Trophic  and  toxic  cases  (amaurotic  family  idiocy  ; 
cerebral  degeneration  with  symmetrical  changes  in 
the  maculae.  Glandular  inadequacy  (cretinism, 
infantilism).  Sense-deprivation  -  -  51 


CHAPTER  V 
ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS 

Etiology.  —  Hereditary  mental  weakness  —  epileptic, 
neurotic,  etc.  Statistics.  Mendelian  doctrines.  In- 
fluence of  environment.  Inherited  syphilis.  Was- 
sermann  reaction.  Phthisical  family  history.  Par- 
ental intemperance.  Maternal  ill-health,  accident 
or  shock.  Prolonged  parturition — use  of  forceps. 
Premature  birth.  Convulsions  of  teething.  Epi- 
lepsy. Traumatism.  Fright  or  shock.  Severe 
febrile  illnesses. 

Diagnosis.  —  Cranial  abnormalities:  —  (microcephalus; 
hydrocephalus ;  hypertrophic  cases ;  oxycephaly ; 
scaphocephaly) .  Formative  and  developmental  de- 
fects. Abnormality  of  nervous  action.  Defects  in 
nutrition.  Primary  and  secondary  amentia.  Tests 


CONTENTS  xiii 


PAGE 

of  intelligence.  Binet-Simon  scale,  etc.     Achondro- 
plasia.     Mixed  types.     Moral  defectiveness . 
Prognosis  in  various  types.     Mongol,  Cretin  and  other 

definite  types  -  -     83 


CHAPTER   VI 

THE  PSYCHOPATHIES  OF  PUBERTY  AND 
ADOLESCENCE 

Juvenile  general  paralysis  of  the  insane.  Dementia  prae- 
cox.  Developmental  epilepsy  and  epileptic  mental 
degeneration.  Pubertal  perversion  of  moral  sense. 
Hysterical  affections.  Insanity  in  childhood.  Minor 
mental  and  moral  changes  -  -  142 


CHAPTER  VII 

^VIEDICAL    EXAMINATION  OF  MENTALLY 
DEFECTIVE    CHILDREN   UNDER  THE    REGULA- 
TIONS OF  THE  BOARD  OF  EDUCATION 

'Model  arrangements."  Forms  and  certificates.  Binet- 
Simon  and  other  tests.  Pasmore's  "  Flag  "  Chart  of 
Heredity.  Backward  classes.  Print  of  Schedule  F  153 

CHAPTER  VIII 

THE  TREATMENT  OF  MENTALLY  DEFICIENT 
CHILDREN 

(a)  General. — Maternal  care.  Proper  feeding.  Hygiene 
of  skin.  Muscular  activity  to  be  encouraged. 
Cleanly  habits  to  be  inculcated.  Clothing.  Exer- 
cise. Care  at  puberty.  (b)  Medical. — Coexistence 
of  physical  and  mental  defects.  Tuberculosis.  Mu- 
cous diarrhoea.  Epilepsy.  Sporadic  cretinism. 
Parasitic  and  other  skin  diseases,  (c)  Surgical  opera- 
tions in  bone  and  joint  disease.  Craniectomy  -  170 


CONTENTS 


CHAPTER  IX 
EDUCATIONAL  TRAINING 

PAGE 

Culture  of  the  external  senses.  Co-ordination  of  mus- 
cular movement.  Promotion  of  manual  and  mental 
activities,  (i)  Dull  and  apathetic,  (2)  Nervous 
children.  Devices  for  fixing  attention  and  for  exer- 
cising adjustments  of  fingers  (illustrated).  Montes- 
sori  "  didactic  material."  Training  of  touch,  sight, 
taste,  smell,  hearing,  speech.  Echolalia.  Idioglossia. 
Drill  and  dressing  lessons.  Object-lessons.  Draw- 
ing, writing,  reading,  and  calculation.  Influence  of 
music  -------  186 


^_^  .  CHAPTER  X 

INDUSTRIAL  TRAINING   AND    RECREATION 

Kindergarten  occupations.  Outdoor  work.  Handi- 
crafts. Recreations.  Games  of  ball;  marbles; 
skipping;  battledore  and  shuttlecock;  dancing;  baga- 
telle. Concerts  and  theatrical  performances.  Speci- 
men curricula  of  L.C.C.  Special  Schools  -  207 


CHAPTER  XI 

MORAL  TRAINING 

Specially  essential  in  education  of  mentally  deficient 
children.  Moral  discipline;  "force  no  remedy"; 
rewards  and  punishments.  The  morally  defective 
child.  Sequestration  and  sterilisation.  Religious 
feeling  in  mentally  deficient  children  -  216 


CONTENTS 

CHAPTER  XII 

RESULTS  AND  CONCLUSIONS 

Pessimistic  views  as  to  possibility  of  improving  defec- 
tive  children.  Experience  of  Seguin,  of  English,  of 
American  Institutions,  and  of  Special  Schools. 
Necessity  of  "  after-care."  Statistics.  Proportion 
fit  for  employment.  Earning  capacity.  Relief  to 
parents.  Examples.  Question  of  marriage  and  of 
permanent  sequestration.  Special  school  education 
and  its  results  and  shortcomings.  Working  homes 
and  colonies  for  mental  defectives.  Objections  to 
efforts  to  educate  mentally  deficient  children.  The 
humanitarian  and  Christian  aspects  of  the  subject  -226 


APPENDICES 

A.  —  LIST  OF  INSTITUTIONS  RECOGNISED  UNDER  MENTAL 

DEFICIENCY  ACTS,  AND  OF  M.  A.  B.  INSTITUTIONS, 
INSTITUTIONS  IN  IRELAND  AND  BRITISH  DOMIN- 
IONS -  244 

B.  —  LIST    OF    PUBLIC    AND    PRIVATE    INSTITUTIONS    IN 

UNITED  STATES  OF  AMERICA  -  -  256 

C.  —  TABLE  OF  SPEAKING  EXERCISES        -  -  260 

D.  —  TIME  TABLE  L.C.C.   SPECIAL  SCHOOL  FOR  ELDER 

BOYS  -  -  -  262 

E.  —  FORM    OF   MEDICAL   CERTIFICATE   UNDER   MENTAL 

DEFICIENCY  ACT    ....  -  264 

BIBLIOGRAPHY  -  -  -  -  265 

INDEX  OF  SUBJECTS    -  .  -  274 

INDEX  OF  NAMES        .  283 


LIST  OF  ILLUSTRATIONS 

PLATES. 
Plate  I.-— Defects  in  Development.  [facing  p.  12 

FIG.  i. — Misshapen  "  Morel  "  Ears. 

,,  2. — Convoluted  Scalp. 

,,  3. — Ear  showing  Darwinian  Tubercle. 

,,  4. — Frontal  Corrugation  in  Mongolian  Imbecile. 

Plate  II. — Abnormalities  in  Brain  Structure.        [facing  p.  55 

FIG.   i. — Porencephalus. 
,,      2. — Cerebellar  Defect. 

Plate  III. — Microcephalic  Brains.  [facing  p.  59 

FIG.   i. — Convexity  (half  natural  size). 

2. —         ,,     "  '  "  Freddy  "  (natural  size). 

Plate  IV.— Microcephalic  Cases.  [facing  p.  60 

FIG.  i.—"  Freddy  "  (R.  A.  A.) 
,,  2. — Special  School  (boy). 
,.  3-—  „  M  (girl). 

Plate  V.— Hydrocephalic  Cases.  [facing  p.  61 

FIGS,  i  and  2. — Portraits. 

Plate  VI.—  Mongol  Brain.  [facing  p.  62 

FIG.   i. — Convexity. 
,,      2. — Base. 

3. — Left  Lateral  View, 
xvii 


LIST  OF  ILLUSTRATIONS 


Plate  VII. — From  Journal  of  Psycho- Asthenics.    [facing  p.  63 

FIG.   i. — American  Imbecile  with  Leptocephalic 

Cranium. 

,,      2.— American  Imbecile  with  Scaphocephalic 
Cranium. 

Plate  VIII.— Inherited  Syphilis.  [facing  p.  70 

Plate  IX.— Birth  Palsy.  [facing  p.  72 

FIG.   i.— Girl  (R.  A.  A.). 

2. — Boy,  showing  Athetosis  (R.  A.  A.). 

Plate  X. — Oxycephalic  Case.  [facing  p.  73 

FIG.   i. — Front. 
2. — Profile. 

Plate  XI. — Sporadic  Cretins.  [facing  p.  79 

-pic.   i. — Female  Cretin. 

2. — "  Sarah,"  aged  twenty-two  years. 

Plate  XII.— Cranial  Contours.  [facing  p.  105 

Plate  XIII.— Reduced  Cranial  Skiagram  (anterior  view) 

[facing  p.   108 

Plate  XIII .A.  — Reduced  Cranial  Skiagram  (adjoining- 
lateral  view)  [  following  Plate  XIII. 

Plate  XIV.— Mongolian  Type.  [facing  p.  119 

FIG.   i. — "  Mongol  "  Profile. 
2. — "  Mongol  "  Tongue. 

Plate  XV.— (FIGS,  i  and  2).—"  Mongol  "  Hands. 

[facing  p.  120 

Plate  XVI.— Wood-Carving  by  J.  B.  (R.  A.  A.)    [facing p.  127 
Plate  XVII.— Heredity  Chart  (Dr.  Pasmore).       [facing  p.  163 


LIST  OF  ILLUSTRATIONS  xix 

Plate  XVIII.— J.  L.  ("  Diogenes  ")  (R.  A.  A.)       \facingp.  175 

Plate  XIX.— Sporadic  Cretins.  [facing  p.  182 

FIG.  i. — Before  Treatment. 
2. — After  Treatment. 

Plate  XX.— The  Same  after  Ten  Years'  Continued  Treat- 
ment, [facing  p.  183 

ILLUSTRATIONS  IN  THE  TEXT 

FIG.  i. — American  Cretins  -     80 

,,  2. — -Microcephalic  Idiot,  aged  twenty  -  105 

,,  3. — Contours  of  Scaphocephalic  Cranium    -  -  108 

,,  4. — Peg-Board  -   189 

,,  5. — Size-Board  -   193 

,,  6. — Form-Board        -  -  193 

,,  7. — Graduated  Wooden  Rods  -  194 

,,  8. — Domino-Bcfards                                 «  -   194 


MENTALLY    DEFICIENT 
CHILDREN 

THEIR  TREATMENT  AND  TRAINING 
CHAPTER  I 

HISTORICAL  RETROSPECT 

NEARLY  eighty  years  have  now  passed  since  serious 
and  systematic  efforts  were  first  made  to  improve  the 
condition  of  the  mentally  deficient  child.  The  labours 
of  Seguin,  at  the  Bicetre  Hospital  in  Paris,  gave  the 
first  impetus  to  scientific  work  having  for  its  object 
(in  the  words  of  Esquirol)  "  the  removal  of  the  mark 
of  the  beast  from  the  forehead  of  the  idiot."  Some 
such  efforts  had  indeed  been  previously  made  in  France 
by  Itard,  Voisin,  Esquirol,  and  others;  and  the  ex- 
periments of  Itard  on  the  boy  found  running  wild  in 
the  woods  of  Aveyron  (le  sauvage  de  I'Aveyron),  of 
which  he  published  an  account  in  1801,  doubtless  con- 
tributed to  a  rational  understanding  of  congenital 
defects  of  intellect.  In  1837  Seguin,  an  old  pupil  of 
Itard  and  Esquirol,  essayed  to  instruct  an  idiot  child, 
and  after  gaining  experience  and  successful  results  at 
the  Hospital  for  Incurables,  he  was  appointed  in  1842 
to.  apply  his  method  to  the  education  of  the  idiot 
children  of  the  Bicetre.  About  the  same  date, 


•±  MENTALLY  DEFICIENT  CHILDREN 

Dr.    Saegert,    in   Berlin,    and     Dr.    Guggenbiihl,    in 
Switzerland,  independently  took  in  hand  the  ameliora- 
tive   treatment    of   mentally    feeble    children.     The 
conspicuous  success  of  the  work  of  Guggenbiihl  in 
improving  the  condition  of  cretins  by  removing  them 
from  sequestered  and  shadowed  Alpine  valleys  to  the 
sunshine  of  the  summit  of  the  Abendberg,  made  a 
great  impression  on  philanthropists  in  Europe  and 
America,  and  demonstrated,  as  by  an  object-lesson, 
the  interdependence  of  physical  and  mental  ameliora- 
tion.    Saegert  seems  to  have  laboured  somewhat  on 
the  lines  of  the  instruction  he  had  been  accustomed 
to   give   to   deaf-mutes,   with   such   adaptations   as 
were   necessary   to   the   case   of   imbecile   children. 
The  school  he  established  is  still  carried  on  in  Berlin, 
though  with  the  disadvantage  of  being  organised  as 
a  department  of  a  lunatic  asylum.     It  was  a  curious 
coincidence  that  almost  simultaneously  in  France, 
Switzerland,  and  Germany,  independent  efforts  were 
inaugurated  for  the  benefit  of  the  mentally  defective 
class;  and  the  year  1842  must  be  looked  upon  as  an 
epoch  memorable  in  this  matter.     Although  Seguin 
is  entitled  to  the  credit  of  priority,  he  himself  modestly 
avers  that  "  at  certain  times  and  eras,  the  whole  race 
of  man  as  regards  the  discovery  of  truth,  seems  to 
arrive  at  once  at  a  certain  point,  so  that  it  is  hard  to 
say  who  is  the  discoverer."     In  1843,  however,  the 
illustrious  Voisin  publicly  recognised  the  work  and 
merits  of  Seguin.     His  prognostications  that  Seguin 
would  "  be  entitled  by  his  psychological  contributions 
to  take  a  distinguished  place  among  his  contem- 
poraries "  were  justified  by  the  publication,  in  1846, 
of    Seguin's    magnum    opus    entitled    ff  Traitement 
moral,  Hygiene  et  Education  des  Idiots  et  des  autr.es 
Enfants  Arrieres."     This  book  may  indeed  be  re- 


HISTORICAL  RETROSPECT  3 

garded  as  the  magna  charta  of  the  mental  emancipa- 
tion of  the  imbecile  class.* 

Defining  idiocy  as  an  "  infirmity  of  the  nervous 
system,  which  has  for  its  effect  the  abstraction  of 
the  whole  or  part  of  the  organs  and  the  faculties  of 
the  child  from  the  normal  action  of  the  will,"  he 
.  proceeds  to  divide  all  cases  into  two  principal  classes, 
those  of  profound,  and  those  of  superficial  idiocy. 
The  basis  of  the  treatment  he  proposes  is  almost 
identical  with  that  described  in  later  works  as  physio- 
logical education.  Starting  with  the  axiom  that 
"  The  education  of  the  senses  must  precede  the 
education  of  the  mind/'  he  argues  that  the  true 
physiological  method  of  tuition  for  persons  whose 
nervous  system  is  imperfectly  developed  is  (i)  "  to 
exercise  the  imperfect  organs  so  as  to  develop  their 
functions/'  and  (2)  '  to  train  the  functions  so  as  to 
develop  the  imperfect  organs."  Ingenious  devices 
are  described  whereby  the  sense-organs  may  be 
methodically  exercised,  and  cases  are  given  in  minute 
detail  in  which  such  exercises  have  been  adapted  to 
special  incapacities. 

\In  Great  Britain  interest  had  been  aroused  by 
the  publication,  in  1843,  of  an  account  by  Dr.  William 
Twining  of  what  he  had  witnessed  at  Guggenbuhl's 
Institution  on  the  Abendberg.  This,  indeed,  led 
to  the  establishment,  in  1846,  of  a  small  school  for 
imbeciles  at  Bath,  under  the  management  of  the 
Misses  White,  subsequently  carried  on  as  a  benevolent 
establishment  by  Miss  Heritage.  This  has  now 
developed  into  the  Magdalen  Hospital  School,  Combe 

*  For  further  particulars  as  to  Seguin,  the  reader  is  referred 
to  a  recent  excellent  work,  Seguin  and  his  Physiological 
Method  of  Education,  by  Henry  Holman,  M. A.  London :  Sir 
Isaac  Pitman  and  Co.,  1914. 


MENTALLY  DEFICIENT  CHILDREN 


Down,  under  the  management  of  the  Trustees  of  the 
Municipal  Charities  ol  Bath.  It  is  a  matter  of 
archaeological  interest  to  note  that  this  Institution 
owes  its  establishment  in  1891  to  an  Order  of  the 
Charity  Commissioners  amalgamating  the  school 
above  referred  to  with  an  ancient  charity  founded 
in  the  twelfth  century  as  a  leper  hospital  in  connec- . 
tion  with  the  Priory  Chapel  of  St.  Mary  Magdalen, 
Bath.  It  seems  probable  that  as  the  demand  for 
the  accommodation  of  lepers  diminished,  lunatics  and 
idiots  took  their  place.  Thus  the  Bath  Institution 
may  claim,  by  right  of  succession,  to  be  the  most 
ancient  foundation  in  Great  Britain  for  this  class  of 
cases,  and  it  is  on  record  that  "  idiots  "  were  in 
residence  at  the  Magdalen  Hospital  early  in  the 
eighteenth  century.  Articles  by  Mr.  Gaskell  (after- 
wards a  Lunacy  Commissioner)  and  Dr.  Conolly 
(the  enlightened  Superintendent  of  Hanwell  Asylum) 
upon  the  work  of  Seguin  at  the  Bicetre,  which  ap- 
peared in  1847,  ted  to  a  further  practical  development 
in  England,  and  in  1848,  Park  House,  Highgate,  the 
mother  institution  of  Earlswood  and  of  the  Eastern 
Counties  Asylum  at  Colchester,  opened  its  doors  for 
the  treatment  and  training  of  idiots  and  imbeciles, 
Dr.  Conolly  and  Dr.  Reed  acting  as  its  gratuitous 
secretaries. 

yL  Meanwhile  the  New  World  was  closely  treading 
upon  the  heels  of  the  Old  in  the  march  of  progress 
in  the  education  of  imbeciles.  Early  efforts  had 
been  made  in  the  most  progressive  of  the  United 
States  to  benefit  idiots  by  training  them  in  con- 
nection with  special  schools  for  the  deaf,  and  for 
the  blind;  but  Massachusetts  was  the  first  to  move 
in  specific  provision  for  this  class  by  appointing 
"  Commissioners  to  inquire  into  the  condition  of 


HISTORICAL  RETROSPECT 


idiots  in  the  Commonwealth,  to  ascertain  their 
number,  and  whether  anything  can  be  done  for  their 
relief/'  Dr.  S.  G.  Howe,  well  known  as  the  successful 
instructor  of  the  blind  deaf-mute,  Laura  Bridgman, 
was  the  Chairman  of  this- Commission.  Their  Report, 
issued  in  1848,  with  elaborate  statistical  tables,  led 
to  a  grant  by  the  Legislature  of  2,500  dollars  for  the 
establishment  of  an  "  experimental  school  for  feeble- 
minded children";  and  about  the  same  time  a 
private  school  was  opened  at  Barre,  Mass.,  by  Dr. 
H.  B.  Wilbur,  being  "  designed  for  the  education  and 
management  of  all  children  who  by  reason  of  mental 
infirmity  are  not  fit  subjects  for  ordinary  school 
instruction."  In  1851  an  "  experimental  school " 
was  started  by  the  State  of  New  York;  this  subse- 
quently developed  into  the  State  Asylum  at  Syracuse, 
over  which  Dr.  H.  B.  Wilbur  long  and  ably  presided. 
The  first  Report  of  the  Trustees  so  well  sets  forth 
the  aims  and  limitations  of  training  that  we  are 
tempted  to  quote  a  few  lines  as  follows: 

11  We  do  not  propose  to  create  or  supply  faculties 
absolutely  wanting;  nor  to  bring  all  grades  of  idiocy 
to  the  same  standard  of  development  and  discipline; 
nor  to  make  them  all  capable  of  sustaining  creditably 
all  the  relations  of  a  social  and  moral  life ;  but  rather 
to  give  to  dormant  faculties  the  greatest  possible 
development,  and  to  apply  these  awakened  faculties 
to  a  useful  purpose  under  the  control  of  an  aroused 
and  disciplined  will.  At  the  base  of  all  our  efforts 
lies  the  principle  that,  as  a  rule,  none  of  the  faculties 
are  absolutely  wanting,  but  dormant,  undeveloped, 
and  imperfect/'  After  the  decease  of  Dr.  Wilbur,  in 
1883,  the  "  Syracuse  State  Institution  for  Feeble- 
minded Children  "  (as  it  is  now  designated)  was 
directed  by  Dr.  J.  C.  Carson,  who  resigned  in  1912 


6          MENTALLY  DEFICIENT  CHILDREN 

"  after  twenty-seven  years  of  diligent  and  efficient 
service/'  and  was  succeeded  by  Dr.  O.  H.  Cobb;  the 
Institution  now  has  626  inmates. 

Pennsylvania  was  the  next  to  establish  a  "  Train- 
ing School  for  Feeble-minded  Children."  Taking  up 
the  private  enterprise  of  Mr.  J.  B.  Richards,  a  State- 
aided  charity  was  formed,  in  1853,  which,  under 
its  late  Superintendent,  Dr.  Isaac  Kerlin,  and  his 
assistant  and  successor,  Dr.  Martin  Barr,  has  become 
(at  Elwyn)  a  model  village  for  the  feeble-minded. 

The  State  of  Ohio  provided  for  her  feeble-minded 
children  in  1857;  the  Institution  at  Columbus,  with 
its  splendid  stock-farm,  is  appointed  on  a  liberal 
scale,  and  contains  about  1,500  inmates  under  the 
care  of  Dr.  Emerick,  the  successor  of  Dr.  Doren,  who 
for  over  thirty  years  wisely  directed  its  development. 

Connecticut,  Kentucky,  and  Illinois,  were  also 
early  in  the  field,  having  established  State  Institu- 
tions for  the  feeble-minded  between  1855  and  1865. 
It  is  noteworthy  that  all  the  early  American  Schools 
were  organised  on  strictly  educational  lines,  the  im- 
becile institution  being  regarded  (in  the  words  of 
Dr.  Howe)  "  as  a  link  in  the  chain  of  common  schools 
— the  last  indeed,  but  still  a  necessary  link  to  embrace 
all  the  children  in  the  State." 

The  influence  of  Dr.  Seguin,  who,  after  migrating 
from  Paris  to  the  United  States  in  1850,  was  asso- 
ciated with  the  organisation  of  several  of  the  early 
American  Institutions,  inspired  enthusiasm  in  the 
educational  work,  and  perhaps  a  somewhat  exag- 
gerated belief  in  its  possibilities.  The  sanguine 
views,  however,  put  forth  in  some  of  the  early  Reports 
gradually  sobered  down  with  experience,  and  in  1872 
Dr.  Wilbur  set  forth  to  his  Trustees  in  clear  language 
the  limitations  inevitable  in  cases  of  original  defect. 


HISTORICAL  RETROSPECT 


11  The  same  limitations "  (he  writes)  "  hold  here 
as  in  any  other  system  of  education.  These  depend 
upon  the  individual  capacities  of  the  pupil.  Now 
and  then  one  of  the  pupils  absolutely  passes  from 
the  condition  of  idiocy,  and  leaves  the  Institution 
capable  of  caring  for  himself  thereafter.  These  are 
the  exceptions;  the  rule  is  otherwise.  Ordinarily, 
the  highest  aim  of  the  training  is  to  send  out  the.  sub- 
ject of  it,  at  the  end  of  the  course,  so  improved  as  to 
be  capable  of  some  useful  occupation,  under  intelli- 
gent direction."  He  pointed  out  that  these  conditions 
involve  the  necessity  of  supplementary  custodial  insti- 
tutions, and  from  this  time  forward  such  a  considera- 
tion seems  to  have  been  more  of4  less  kept  in  mind 
in  the  provision  of  State  care  for  the  feeble-minded. 

In  1898,  according  to  Dr.  F.  M.  Powell's  Report  to 
the  National  Conference  of  Charities  and  Correction, 
there  existed  twenty-four  public  Institutions  for  this 
class,  maintained  by  nineteen  States,  and  one  by  the 
city  of  New  York.  From  a  statement  which  appeared 
in  an  American  philanthropic  journal,  The  Survey,  in 
1912  one  gathers  that  in  all  but  eighteen  of  the  States 
of  the  Union  some  public  provision  of  a  residential 
character  has  now  been  made  for  the  mentally  de- 
ficient class,  and  that  about  25,000  in  the  aggregate 
are  thus  accommodated,  as  compared  with  8,492  in 
1898.  This  statement  does  not  include  private 
schools  or  the  special  (day)  classes  established  in  some 
of  the  cities.  It  would  appear,  from  the  Bulletin 
for  1911  of  the  United  States  Bureau  of  Education, 
that  99  cities  have  established  special  classes  for 
mentally  defective  children,  while  220  classes  for 
mentally  backward  children  have  also  been  organised./ 

In  our  own  country  comparatively  little  progress 
has  been  made  in  recent  years  in  providing  out  of 


MENTALLY  DEFICIENT  CHILDREN 


public  funds  Institutions  exclusively  for  the  mentally 
defective  class.  Those  of  the  Metropolitan  Asylums 
Board,  affording  accommodation  for  about  7,000  adult 
imbeciles  and  harmless  lunatics  and  1,500  children, 
have  been  in  existence  for  upwards  of  forty  years 
under  the  Metropolitan  Poor  Act  of  1867.  But  else- 
where only  sporadic  attempts  have  been  made  by 
Guardians  of  the  Poor  to  form  special  establishments 
apart  from  workhouse  accommodation  for  imbeciles 
and  feeble-minded  falling  under  their  charge.  The 
most  notable  example  of  a  provincial  Poor  Law 
Institution  is  that  originally  provided  by  a  combina- 
tion of  the  Birmingham,  Aston,  and  King's  Norton 
Guardians  at  Monyhull  in  1908;  the  present  estab- 
lishment, now  under  "  the  Greater  Birmingham  " 
Board  of  Guardians,  is  known  as  the  Monyhull  Colony 
for  sane  epileptics  and  feeble-minded  persons  charge- 
able to  the  Board.  On  an  estate  of  185  acres  252 
adult  inmates  were  originally  provided  for  in  several 
separate  houses;  extensions  are  in  progress  to  bring 
up  the  accommodation  to  12  homes  for  an  aggregate 
of  504  adults,  and  8  homes  for  76  epileptic  and  270 
feeble-minded  children,  230  of  the  latter  to  be  main- 
tained by  the  Education  Committee  of  Birmingham. 
A  school  with  300  places,  workshops  and  laundry,  is 
also  to  be  provided.  At  the  colony  100  beds  are 
required  for  cases  sent  under  certificate  by  the  Bir- 
mingham Committee  for  the  care  of  the  Mentally 
Defective.  Stimulated  by  the  passing  of  the  Mental 
Deficiency  Act,  other  Poor  Law  Guardians  are  also 
moving  in  the  matter;  in  Wiltshire  an  Institution  is 
projected  at  Devizes  for  200  feeble-minded  cases, 
and  the  Joint  Committee  of  Glamorgan  Unions  is 
about  to  establish  a  Colony  for  Feeble-minded  on 
the  side  of  the  Drymma  Mountain,  near  Neath.  A 


HISTORICAL  RETROSPECT  g 

combination  of  West  Riding  Guardians  contemplate 
the  provision  of  a  colony  for  feeble-minded  near 
Pontefract;  and  24  Unions  in  the  North-East  of 
England  are  contributing  to  the  establishment  of  an 
Institution  for  Feeble-minded,  and  have  purchased 
Prudhoe  Hall,  with  its  estate  of  125  acres,  in  Nor- 
thumberland, for  the  purpose. 

In  connection  with  County  Lunatic  Asylums, 
annexes  or  special  wards  for  young  imbeciles  have 
been  provided  at  Northampton,  Wandsworth  (Mid- 
dlesex), Fareham  (Hants),  Chartham  (Kent),  Durham, 
Winwick  (Lanes),  Stanley  Hall  (Yorks),  Burnt- 
wood  (Staffs),  Rubery  Hill  (Birmingham),  and  Hel- 
lingly  (East  Sussex),  the  aggregate  accommodation 
being  about  1,000  beds.  It  is  probable  -that  under 
the  Mental  Deficiency  Act  some  rearrangement  will 
be  effected.  Plans  have  recently  been  adopted  by 
the  Kent  County  Council  for  a  special  Institution  for 
Defectives  near  Charing. 

In  recent  years  greater  charitable  enterprise  has 
been  shown  in  the  provision  of  residential  establish- 
ments for  the  mentally  defective.  In  addition  to  the 
six  English  voluntary  Institutions  for  Idiots  and 
Imbeciles — at  Earlswood,  Lancaster,  Starcross,  Col- 
chester, Knowle,  and  Bath,  which  have  been  doing 
good  work  during  the  last  half-century  and  now 
accommodate  some  2,000  patients — the  Sandlebridge 
Colony  of  the  Lancashire  and  Cheshire  Association 
for  Permanent  Care  has  some  300  residents,  children 
and  adults,  and  the  Princess  Christian  Farm  Colony 
near  Tonbridge  about  no.  A  colony  recently  estab- 
lished by  the  Notts  and  Nottingham  Association  ,at 
Hopwell  Hall,  Derbyshire,  accommodates  50  boys, 
and  will  also  admit  50  girls  later  on.  In  Somerset 
it  is  hoped  shortly  to  establish  a  Permanent  Home 


io        MENTALLY  DEFICIENT  CHILDREN 


for  the  feeble-minded  of  that  county  and  Bristol,  a 
site  of  100  acres  having  been  offered  for  the  purpose 
by  Mr.  H.  H.  Wills.  Several  establishments  (The 
National  Institutions  for  Persons  requiring  Care  and 
Control),  including  those  at  Sandwell  Hall  and 
Stoke  Park,  have  been  provided,  mainly  through  the 
activity  of  the  Rev.  H.  N.  Burden,  for  about  1,700 
mentally  defective  children  and  adults.  About  600 
cases,  chiefly  older  feeble-minded  girls,  are  in  small 
voluntary  Industrial  Homes  founded  by  benevolent 
associations  in  various  parts  of  the  country.  The 
first  homes  of  this  kind  were  established  by  the  late 
Miss  Agatha  Stacey  in  1892  near  Birmingham.  If 
we  also  take  into  account  the  14,000  children  attend- 
ing special  schools  in  England  and  Wales — shortly, 
we  trust,  to  be  doubled  when  the  Elementary  Educa- 
tion (Defective  and  Epileptic  Children)  Act  comes 
into  full  operation — it  may  be  said  that  there  is,  in 
one  way  or  another,  provision  for  about  25,000 
mental  defectives  in  England  and  Wales.  In  Scot- 
land the  Institutions  at  Larbert  and  Baldovan  pro- 
vide for  6 io  inmates,*  while  many  of  the  imbecile  and 
feeble-minded  class  are  boarded  out  under  super- 
vision. Special  schools  for  defective  children  also 
exist  in  the  larger  cities  with  places  for  upwards  of 
800  pupils.  In  Ireland  about  120  imbeciles  are 
accommodated  at  the  Stewart  Institution,  near 
Dublin.  The  Board  of  Control  have  acquired,  under 
the  powers  of  the  Act,  premises  at  Maghull,  near 
Liverpool,  for  a  State  Institution  for  defectives  of 
dangerous  or  violent  propensities. 

*  Quite  recently  the  Glasgow  Association  for  the  Feeble- 
minded has  opened  an  Institution  for  Juvenile  Female  Defec- 
tives, and  three  Institutions  for  Adult  Defectives  have  been 
organised . 


HISTORICAL  RETROSPECT  n 


In  the  cursory  survey  of  the  provision  made  for 
mental  defectives  in  Great  Britain  and  in  the  United 
States  it  has  proved  impracticable  satisfactorily  to 
differentiate  between  that  for  children  and  for  adults, 
or  definitely  to  state  the  grade  of  mental  defect  of 
the  inmates  of  the  respective  Institutions.  For  the 
most  part  those  in  America  have  been  designated 
Institutions  for  "  Feeble-minded/'  and  in  Great 
Britain  (until  recently)  "Asylums  for  Idiots  and 
Imbeciles,"  though  both  have  ministered  to  the 
wants  of  similar  classes  of  patients.  In  America,  how- 
ever, the  designation  "  Feeble-minded "  has  long 
been  used  as  a  euphemism  for  all  grades  of  mental 
defect,  including  idiots,  imbeciles,  and  the  higher 
type  to  which  the  appellation  Moron  (from  ^w/>os  =a 
foolish  person)  has  of  late  years  been  applied  by 
Dr.  Goddard  of  the  Vineland  Institution,  U.S.A. 
Though  the  English  Education  (Defective  and  Epi- 
leptic Children)  Act  of  1899  recognised  a  grade  of 
children  higher  than  imbeciles  as  "  mentally  defec- 
tive "  so  as  to  require  special  education,  it  was  not 
until  1908  that  the  Royal  Commission  on  the  Care 
and  Control  of  the  Feeble-minded  gave  precision  to 
the  term  by  denning  as  feeble-minded  "  persons  who 
may  be  capable  of  earning  a  living  under  favourable 
circumstances,  but  are  incapable  from  mental  defect 
existing  from  birth  or  from  an  early  age  (a)  of  com- 
peting on  equal  terms  with  their  normal  fellows;  or 
(b)  of  managing  themselves  and  their  affairs  with 
ordinary  prudence."  It  will  be  seen  later  that  this 
definition,  with  certain  modifications,  has  been 
adopted  in  the  Mental  Deficiency  Act,  1913. 

Under  the  auspices  of  the  British  Medical  Associa- 
tion, the  Charity  Organisation  Society,  the  British 
Association  for  the  Advancement  of  Science,  the  In- 


12        MENTALLY  DEFICIENT  CHILDREN 


ternational  Congress  of  Hygiene  and  Demography, 
and  other  public  bodies,  laborious  investigations  were 
undertaken    nearly   thirty    years    ago,    Dr.    Francis 
Warner  being  the  active  conductor  of  the  inquiry. 
A  "  Report  on  the  Scientific  Study  of  the  Mental  and 
Physical   Conditions   of   Childhood;    with   particular 
reference  to  children  of  defective  constitution;  and 
with  recommendations  as  to  Education  and  Train- 
ing," was  issued  in  1895  by  the  Committee,  Parkes 
Museum,  Margaret  Street,  W.,  based  on  the  examina- 
tion of  50,000  children  seen  in  1888-91,  and  of  another 
50,000    seen    in    1892-94.     Whilst    100,027    children 
passed    in   groups    under    the    eye    of  the  medical 
examiner,  the  number  of  children  individually  noted 
and  registered  was  18,127,  no  note  being  taken  of  the 
81,900    children    not    presenting    obvious    physical 
defect,  or  not  reported  by  teachers  as  mentally  dull. 
Defects   in   development*    such   as    abnormalities    of 
cranium,  of  external  ear,  of  eyelids,  of  palate,  of  nasal 
bones,  and  of  stature,  were  noticed  in  9,777  cases; 
abnormal  nerve  signs,  such  as  defect  in  general  balance, 
overacting     f rentals,    corrugation,  f    defective     eye 
movements,    defects   of   balance   of   head   or   hand, 
finger-twitches  and  lordosis,  together  with  deafness, 
defective  speech,  slow  response,  etc.,  were  observed 
in  10,355  cases;  low  nutrition  was  registered  against 
3,522  children,  who  were  pale,  thin,  or  delicate;  and 
7,391  children  were,  on  report  of  teachers,  entered  as 
mentally    dull.     Obvious    eye-defects    were    noted    in 
2,929  cases:  evidences  of  rickets  (other  than  cran;al) 
were  registered  in  244;  811  children  were  put  down 
as  "  exceptional/'  including  2  idiots,   51  imbeciles, 
275   children   feebly  gifted  mentally,    19  "  mentally 
exceptional  "  (moral  imbeciles,  etc.),  no  epileptics, 
5   deaf-mutes,   374  children   crippled,   maimed,   and 

*  See  Plate  I.,  Figs,  i,  2,  3,  4.          f  See  Plate  I.,  Fig.  4. 


[      PLATE    I. 


IG 


L. — MISSHAPEN  "  MOREL  "  EARS: 
CONGENITAL  IMBECILE. 


FIG.  2. — CONGENITAL  IMBECILE 
WITH  CONVOLUTED  SCALP. 


1/iG.  3. — EAR  SHOWING  DAR- 
WINIAN TUBERCLE. 


FIG.  4. — MONGOLIAN  IMBECILP:,  SHOWING 
FRONTAL  CORRUGATION. 


DEFECTS   IN  DEVELOPMENT. 

From  Journal  oj  Psycho- A sthenics,  vol.  xi.  (by  kind  permission  of 
Drs.  Moorhead  Murdoch  and  A.  C.  Rogers). 


'o  face  p<ii:e  12. 


HISTORICAL  RETROSPECT 


paralysed.  Elaborate  tables  were  given  showing  the 
coincidence  and  co-relation  of  the  various  classes  of 
defects ;  but  we  must  content  ourselves  with  quoting 
the  following  estimate  from  the  body  of  the  Report 
(p.  28)  of  the  co-relation  of  binary  defects  in  develop- 
ment (two  malformations  coincident  in  the  same  case) 
in  percentages,  thus: 

"  With  mental  dulness  .  .  •  45'7 
With  low  nutrition  .  .  .31*0 
With  nerve  signs  .  .  .  60-3." 

This  co-relation  is  higher  than  for  single  defects,  and 
it  is  remarkable  that  the  number  of  combined  defects 
was  much  higher  in  the  case  of  boys  than  of  girls — -i-e-,^ 
in  the  proportion  of  1,240  to  683.*  With  the  excep- 
tion of  "  low  nutrition,"  defective  conditions  are 
more  common  in  boys  than  in  girls;  though  when 
defects  occur  they  are  usually  of  more  serious  char- 
acter in  the  case  of  the  latter. 

The  general  conclusion  arrived  at  with  regard  to 
children  that  require  special  care  and  training  is  that 
the  proportion  varies  from  1-6  per  cent,  of  the  first 
series  of  50,000  cases  to  0-88  of  the  second  series  of 
50,000.  Putting  both  series  together,  we  get,  for 
the  100,000  cases  observed,  a  percentage  of  1-261  as 
requiring  special  instruction,  but  it  must  be  remem- 
bered that  this  proportion  includes  278  children  on 
the  score  of  physical  defects  only,  without  signs  of 
mental  dulness. 

These  figures  correspond  approximately  with  the 
findings  of  the  Royal  Commission  on  the  Care  and 
Control  of  the  Feeble-minded,  who  said,  in  1908, 
that  "  in  England  and  Wales  the  number  of  men- 
tally defective  children  may  be  expected  to  be,  in 
the  areas  urban  and  rural,  0-79  per  cent,  of  the  number 

*  26,287  boys  and  23,713  girls  were  seen  in  this  series  of 
cases. 


I4        MENTALLY  DEFICIENT  CHILDREN 

of  children  on  the  school  registers,  falling  as  low  as 
0-28  in  a  northern  colliery  district,  and  rising  as  high 
as  i -12  and  1-24  in  urban  areas." 

Dr.  Warner's  methods  are  based  on  the  principle 
that  "  all  expression  of  nerve  states  and  of  mental 
action  is  by  movements  and  results  of  movement/'* 
and  consequently  abnormal  movements,  and  even 
attitudes,  may  be  taken  to  denote  abnormal  nerve 
states  or  mental  action.  Correlated  with  these  are 
frequently  found  defects  in  development  and  in  nutri- 
tion. Mental  dulness  is  found  associated  with  these 
physical  abnormalities,  which  may  be  regarded  as,  at 
any  rate,  warning  notes  of  intellectual  defect. 

Dr.  Warner's  actual  procedure  when  inspecting  a 
school  is  as  follows : 

"  The  pupils  are  observed  as  they  stand  in  rank, 
usually  a  standard,  or  a  smaller  section  at  a  time. 
The  inspector,  standing  in  front  of  each  child,  in 
turn  holds  a  shilling  for  him  to  look  at,  so  as  to  fix 
his  eyes  and  thus  obtain  a  full  face,  as  well  as  a 
profile,  view  of  each  side,  noting  the  features  separ- 
ately, the  cranium,  the  expression  and  muscular  action 
of  the  parts  of  the  face,  the  eye  movements  and  other 
points.  The  trained  observer  can  read  off  the  points 
in  the  physiognomy  of  the  individual  features  and 
their  parts,  noting  the  proportion  and  form  of  each. 

"  Having  inspected  each  child  in  the  line,  as 
described,  the  children  are  asked  to  hold  out  their 
hands  in  front  of  them,  and  for  a  moment  the  action 
is  done  before  them.  The  balance  of  the  hand,  spine, 
shoulders,  as  well  as  the  arms,  hands,  and  fingers, 
are  noted  in  each  case ;  finally  the  observer  places  his 
hand  on  the  head,  noting  the  size,  form,  bosses,  etc., 
and  the  palate  is  inspected  in  each  case. 

*  Milroy  Lectures,  1892. 


HISTORICAL  RETROSPECT  15 

"  At  each  of  these  stages  in  the  inquiry,  children 
presenting  deviations  from  the  normal,  in  any  par- 
ticular, are  asked  to  stand  aside.  The  teachers  are 
then  asked  to  present  any  exceptional  or  dull  children 
not  picked  out  by  the  observer. 

"  Each  selected  child  is  examined  individually, 
and  noted  on  a  schedule  form*  in  which  the  defect  or 
abnormal  size  is  verbally  described,  and  the  teacher's 
report  of  the  child's  mental  status  is  added.  The 
name,  age,  and  standard  of  each  child  is  entered,  and 
the  number  of  children  seen  in  each  standard  is 
recorded." 

The  systematic  application  of  physical  observa- 
tion to  large  masses  of  school-children  shed  much 
light  upon  educational  problems  which  had  hitherto 
been  regarded  too  exclusively  from  the  psychological 
standpoint.  The  medical  inspection  of  elementary 
schools  now  established  by  law  affords  opportunity 
of  extending  similar  observations.  It  has  long  been 
the  practice  in  dealing  with  imbecile  children  to  note 
in  the  Institution  Case-books  the  physical  as  well  as 
mental  abnormalities  of  each.  Seguin  more  than 
fifty  years  ago  drew  attention  to  the  co-relation 
of  such  abnormalities,  and  in  1883  Dr.  Shuttleworth 
published  in  the  Liverpool  Medico-Chirurgical  Journal 
a  paper  on  "  The  Physical  Features  of  Idiocy,"  tracing 
the  characteristic  physical  abnormalities  coincident 
with  certain  special  types  of  mental  defect.  These 
consisted  mainly  of  what  are  termed  by  Dr.  Warner 
developmental  defects,  but  which  it  must  be  remem- 
bered are  for  the  most  part  congenital,  and  usually 
of  permanent  significance.  As  regards  the  other 
conditions  noted  in  Dr.  Warner's  Report,  abnormal 
nerve  signs,  low  nutrition  and  mental  dulness  may 

*  Recording  Card  subsequently  used.    See  Report,  p.  17. 


16       MENTALLY  DEFICIENT  CHILDREN 

be  of  a  more  or  less  temporary  character,  and  to  a 
large  extent  influenced  by  surroundings,  and  conse- 
quently alterable  by  training.  This  consideration, 
whilst  pointing  to  the  utility  of  such  observations, 
also  discloses  a  possible  source  of  fallacy.  A  class 
of  children  accustomed  to  physical  drill  will  show 
fewer  "  nerve-signs  "  than  a  class  not  so  exercised, 
but  it  would  be  wrong  to  conclude  that  the  intellectual 
standard  of  the  former  is  necessarily  superior  to  that 
.  of  the  latter.  So  again  "  low  nutrition"  may  be 
the  result  of  ill-feeding,  or  may  be  due  to  consti- 
tutional defects.  In  both  cases  intellectual  activity 
may  be  diminished;  but  the  latter  condition  is  more 
serious  than  the  former.  "  Mental  dulness,"  as  re- 
ported by  the  teacher,  is  a  varying  quantity  in  pro- 
portion to  the  educational  standard  aimed  at  in  the 
particular  school,  and  also  in  view  of  the  pupil's  state 
of  health  at  the  time.  The  prudent  medical  examiner 
of  children  alleged  to  be  defective  will  not  allow  him- 
self to  be  swayed  too  much  by  any  one  class  of  observa- 
tions, for  it  is  only  by  comparing  the  signs  of  physical 
abnormality  with  those  of  mental  defect,  educational 
attainments  being  ascertained  and  weighed  in  the 
balance  with  those  of  similarly  placed  normal  children 
of  corresponding  age,  that  a  right  judgment  can  be 
arrived  at. 

A  comprehensive  statistical  inquiry,  prompted  by 
the  Teachers'  Associations  of  Switzerland,  and  con- 
ducted on  pedagogical  rather  than  physiological  lines, 
was  instituted  by  the  Swiss  Government  in  1897,  to 
deteimine  the  number  of  children  of  school  age  weak 
in  mind  (faibles  d' esprit),  those  afflicted  with  physical 
infirmities,  idiots,  deaf-mutes,  and  blind;  and  finally 
those  morally  unfit  for  tuition  in  ordinary  schools. 
The  results  tally  closely  with  those  obtained  in  Eng- 


HISTORICAL  RETROSPECT  17 


land  by  a  more  purely  physical  method.  Out  of 
490,252  children  of  school  age  in  Switzerland,  7,667^ 
or  i -5  per  cent.,  were  returned  as  mentally  feeble. 
This  does  not  include  the  other  categories  mentioned 
above,  one  of  which  comprises  "  idiots,"  of  the  number 
of  whom,  however,  we  have  no  exact  information. 
Altogether  13,155  children  were  returned  as  suffering 
from  some  degree  of  mental,  physical,  or  moral 
infirmity.  Of  the  7,667  children  returned  as  feeble- 
minded, it  is  stated  that  567  already  receive  instruc- 
tion in  special  classes,  that  411  are  in  special  estab- 
lishments, that  104  are  in  orphanages  or  similar 
institutions,  and  do  not  require  special  treatment; 
whilst  for  5,585  is  demanded  individual  care  in  a 
special  class  or  special  institution,  leaving  534  for 
whom  this  is  not  deemed  necessary,  and  466  in  which 
no  opinion  is  given.*  In  March,  1907,  there  were 
recorded  29  resident  institutions  for  feeble-minded 
children  (Geistes-schwache),  public  and  private,  in 
Switzerland,  f  with  1,172  inmates,  besides  67  special 
classes  with  1,415  pupils  and  (in  addition)  623 
children  specially  instructed. 

Dr.  Rudolf  Schwab }  states  that  as  a  result  of 
medical  inspection  in  21  cantons  in  1907  of  children 
who  had  attained  school  age,  the  following  statistics 
were  obtained:  Defective  children,  7,695;  idiots,  41; 
slightly  feeble-minded,  535 ;  markedly  feeble-minded, 
144;  moral  defectives,  43;  the  rest  being  physically 
defective. 

*  "Resultats  du  Denombrement  des  Enfants  faibles 
d'Esprit  en  Age  de  frequenter  1'ficole  "  (iel>  partie).  Statistique 
de  la  Suisse,  ii4e  livraison,  Berne,  1897. 

t  V  evhandlungen  der  VI.  Schweize.  Konferenz  fur  das 
Idiotenwesen,  p.  32, 

J  Kelynack's  Medical  Examination  of  Schools  and  Scholars, 
p.  414. 

2 


CHAPTER  II 
DEFECTIVE  AND  EPILEPTIC  CHILDREN 

PUBLIC  attention  having  been  called,  largely  through 
the  non-official  investigations  referred  to  in  the 
previous  chapter,  to  the  existence  of  a  considerable 
class  of  children  incapable  of  receiving  education  on 
conventional  lines,  the  Lord  President  of  Council 
(as  chief  of  the  Education  Department)  appointed 
in  1896  a  Departmental  Committee  to  inquire  into 
the  existing  systems  for  the  education  of  feeble- 
minded and  defective  children,  "  not  idiots  or  im- 
beciles." 

The  Committee  consisted  of  the  Rev.  T.  W.  Sharpe, 
C.B.,  then  Her  Majesty's  Senior  Chief  Inspector  of 
Schools ;  of  Messrs.  Pooley  and  Newton,  of  the  Educa- 
tion Department ;  of  Mrs.  Burgwin  and  Miss  Douglas 
Townsend;  and  of  Prof.  Wm.  Smith  and  Dr.  Shuttle- 
worth;  Mr.  H.  W.  Orange  acting  as  Secretary.  They 
obtained  information  about  the  English  Institutions 
for  idiots  and  imbeciles,  and  also  with  regard  to  the 
treatment  of  epileptics  at  the  Maghull  Institution. 
They  personally  inspected  the  special  classes  in 
Leicester,  London,  Bradford,  Brighton,  and  Bristol. 

In  consequence  of  their  Report,  an  Act  of  Parlia- 
ment, known  as  the  ''Elementary  Education  (Defec- 
tive and  Epileptic  Children)  Act,"  received  the  Royal 
Assent  in  1899.  This  Act,  which  is  permissive  only, 
enables  school  authorities  to  obtain  grants  from  public 

18 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     19 


money  towards  the  education  of  defective  and  epi- 
leptic children,  subject  to  "  such  conditions  as  may 
be  directed  by  or  in  pursuance  of  the  minutes  of  the 
Education  Department  in  force  for  the  time  being/' 

Under  the  Regulations  issued  in  1907,  children  are 
not   admitted  to   the  special  classes  till  five  years 
.  of  age,  but  the  period  of  education  for  such  children 
is  extended  until  the  age  of  sixteen  years,  and  pro- 
visions are  made  for  boarding  out,  when  necessary, 
either  in  families  or  in  certified  schools,  and  for  the 
school  authority  supplying,  in  cases  requiring  them, 
guides  or  conveyance.     No  requirement  is  made  in 
the  Act  of  1899  as  to  the  appointment  of  Medical 
Officers  either  by  school  authorities  or  the  Education 
Department,  but  it  is  enacted  that  to  bring  a  child 
within  the  purview  of  the  Act  "  a  certificate  by  a  duly 
qualified  practitioner,   approved  by  the  Education 
Department,  shall  be  required  in  each  case."     The 
Education   Act    of    1907    has,    however,    since   laid 
an  obligation  on  all  school  authorities  to  "  provide 
for  the  medical  inspection  of  children  immediately 
before,  or  at  the  time  of,  or  as  soon  as  possible  after, 
their    admission    to    a   public    elementary    school." 
Parents  may  demand  the  examination  of  children 
with  a  view  to  their  admission  to  special  classes,  and 
re-examination  with  a  view  to  their  transfer  to  ordi- 
nary classes  in  public  elementary  schools.     Thanks 
to  the  Elementary  Education   (Defective  and  Epi- 
leptic  Children)    Amendment   Act,    1903,    the   only 
^restriction   on   boarding-schools   is   that   the   school 
must  obtain  the  approval  of  the  Board  of  Education. 
The  Departmental  Committee  estimated  the  num- 
ber of  "  feeble-minded  "  children  at  I  per  cent,  of 
the  school  population,  an  estimate  which  was  shown 
by  the  investigations  of  the  more  recent  Royal  Com- 


20        MENTALLY  DEFICIENT  CHILDREN 

mission  on  the  Care  and  Control  of  the  Feeble-minded 
to  be  fairly  near  the  mark  when  taken  over  the  whole 
country.  This  later  Commission  appointed  medical 
investigators  to  conduct  inquiries  in  nine  selected 
areas,  each  with  a  total  population  of  not  less  than 
150,000.  Their  Reports  showed  that  "  the  northerly 
districts  of  the  Durham  County  and  Hull  stand  best," 
and  "  the  large  urban  areas  come  last."  Thus,  in  a 
mining  district  in  Durham  County  the  proportion  of 
mentally  defective  children  to  the  total  registered 
school  population  was  0*28,  and  in  Hull  and  Scul- 
coates  0-40.  The  rural  areas  show  a  higher  per- 
centage, the  figures  being  wonderfully  uniform,  with 
the  exception  of  the  Lincolnshire  Unions,  which, 
though  rural,  stand  with  the  urban  districts.  Thus 
in  Wiltshire  the  figure  was  0-47,  in  Somerset  0-58, 
and  in  Nottinghamshire  (partly  rural)  0-60.  With 
these  rural  areas  stands  Stoke-on-Trent,  where  the 
medical  investigator,  Dr.  Potts,  reported  well  of  the 
school  population,  in  spite  of  many  drawbacks.  In 
Lincolnshire  the  figure  was  i-io,  leading  up  to  the 
higher  figures  of  1-12  and  1-24  in  Birmingham  and 
Manchester  respectively. 

Epileptic  Children. — The  Departmental  Committee 
estimated  the  number  of  epileptic  children  at  i  per 
i ,000,  of  whom  one-sixth  might  be  classed  as  severely 
afflicted.  They  recommended  that  epileptic  children 
of  normal  intellect  should  be  left  in  ordinary  schools 
if  the  fits  are  not  frequent,  or  violent  fits  do  not  occur 
in  school,  and  that  teachers  be  provided  with  instruc- 
tions as  to  the  treatment  of  children  known  to  be 
epileptic.  Feeble-minded  epileptics  may  be  received 
into  special  classes  when  the  epilepsy  is  not  severe; 
and  for  such  cases  it  may  be  necessary  to  provide 
guides  or  conveyance  between  the  home  and  the 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     2! 


school.  With  regard  to  severe  cases,  whether  men- 
tally feeble  or  otherwise,  treatment  in  residential 
homes  seems  essential,  proper  classification  being 
provided.  Each  house  of  residence  should  consist 
of  one  floor  only,  and  should  not  contain  more  than 
twenty  inmates ;  but  there  may  be  an  aggregation  of 
such  homes  round  an  educational  centre,  as  in  the 
colony  plan.  It  was  recommended  that  school 
authorities  should  have  power  both  to  provide  homes 
and  to  contribute  to  voluntary  homes  which  conform 
to  the  conditions  laid  down. 

The  result  of  these  recommendations  was  that  the 
Act  of  1899  gave  power  to  school  authorities  to  estab- 
lish residential  schools  for  epileptics.  It  did  not, 
however,  give  power  to  board  out  or  to  establish 
special  day-schools  for  epileptics.  For  epileptics  the 
Board  of  Education  certify  boarding-schools  only. 

The  Defective  and  Epileptic  Children  Act  of  1899 
showed  the  number  of  feeble-minded  children  in  our 
big  towns,  and  drew  public  attention  to  them.  It  kept 
many  out  of  mischief  and  under  control  for  some 
hours  of  the  day.  It  was  the  means  of  training  some 
feeble-minded  persons  to  be  self-supporting,  and  of 
educating  a  number  up  to  the  point  of  contributing 
materially  to  their  own  support.  At  the  Conference 
of  After-care  Committees  held  in  London  on  Octo- 
ber 23,  1913,  a  statement  was  presented  by  Sir 
William  Chance,  Chairman  of  the  National  Associa- 
tion for  the  Feeble-minded,  dealing  with  the  Reports 
of  the  After-care  Committees  of  Berkshire,  Birming- 
ham, Bolton,  Bradford,  Brighton,  Bristol,  Bromley 
and  Beckenham,  Leicester,  London,  Northampton, 
Oldham,  Plymouth,  Willesden,  and  Wolverhampton. 
The  combined  statistics  from  these  centres  showed 
that  nearly  50  per  cent,  of  those  who  had  attended 


22        MENTALLY  DEFICIENT  CHILDREN 


special  schools  for  the  mentally  defective  were  doing 
remunerative  work,  the  average  wages  earned  being 
8s.  6d.  per  week  for  boys,  and  6s.  gd.  for  girls.  Such 
encouraging  reports  must,  however,  be  qualified  by 
the  consideration  that  in  some  of  these  centres  a 
number  of  the  successful  cases  were  children  who  had 
been  merely  dull  and  backward,  and  not  really  defec- 
tive, and  also  by  the  further  consideration  that  these 
figures  refer  largely  to  cases  who  have  only  recently 
left  school.  The  Birmingham  After-care  Committee, 
which  v/as  the  first  to  be  formed,  showed  repeatedly, 
after  ten  years'  work,  that  many  of  the  situations 
were  held  for  a  time  only,  periods  of  work  often  alter- 
nating with  longer  periods  of  idleness,  and  that  young 
persons  who  had  just  left  school  were  frequently  the 
most  successful,  and  gradually  deteriorated  as  they 
got  further  away  from  the  time  of  training  and  super- 
vision. This  aspect  of  the  subject  will,  however,  be 
dealt  with  more  fully  in  the  last  chapter. 

Two  drawbacks  attending  the  Act  were  the  fact 
that  no  legislative  action  was  taken  on  the  Com- 
mittee's suggestion  that  the  certificate  excluding  a 
child  from  a  special  class  on  account  of  imbecility 
should  admit  such  child  to  an  institution  for  imbecile 
children,  and  the  fact  that  no  provision  was  made  for 
"  after-care  "  on  leaving  school.  This  latter  omis- 
sion did  much  to  nullify  the  good  effected  by  special 
classes,  even  if  it  did  not  do  worse.  In  the  opinion 
of  many,  education  for  a  few  years,  without  subse- 
quent control,  is  a  dangerous  experiment,  increasing 
as  it  does  the  capacity,  and  in  the  case  of  some  girls 
the  attractiveness,  of  ill  balanced  and  regulated 
natures,  who  ought  to  be  always  under  supervision. 
The  great  disadvantage,  however,  of  the  1899  Act 
was  that  it  was  merely  permissive,  but  by  the  pro- 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     23 


visions  of  the  Amending  Act  of  1914  the  provision  of 
suitable  special  education,  by  means  either  of  day- 
schools  or  residential  establishments,  will  become  the 
duty  of  all  education  authorities. 

As  all  investigations  demonstrated  more  and  more 
clearly  that  the  feeble-minded  constitute  an  impor- 
tant section  of  the  community,  and  that  many  of 
them  require  care  during  the  greater  part,  if  not  the 
whole,  of  their  lives,  a  Royal  Commission  was  ap- 
pointed, in  September,  1904,  to  investigate  the  whole 
problem.  The  reference  required  them  "  to  consider 
the  existing  methods  of  dealing  with  idiots  and  epi- 
leptics, and  with  imbecile,  feeble-minded,  or  defective 
persons  not  certified  under  the  Lunacy  Laws;  and  in 
view  of  the  hardship  or  danger  resulting  to  such 
persons  and  the  community  from  insufficient  pro- 
vision for  their  care,  training,  and  control,  to  report 
as  to  the  amendments  in  the  law  and  other  measures 
which  should  be  adopted  in  the  matter,  due  regard 
being  had  to  the  expense  involved  in  any  such  pro- 
posals and  to  the  best  means  of  securing  economy 
therein."  The  original  reference  was  extended  in 
November,  1906,  "  to  inquire  into  the  constitution, 
jurisdiction,  and  working  of  the  Commission  in 
Lunacy  and  of  other  Lunacy  Authorities  in  England 
and  Wales,  and  into  the  expediency  of  amending  the 
same,  or  adopting  some  other  system  of  supervising 
the  care  of  lunatics  and  mental  defectives;  and  to 
report  as  to  any  amendments  in  the  law  which 
should,  in  their  opinion,  be  adopted/' 

The  Commission  originally  consisted  of  the  Marquis 
of  Bath,  Chairman;  W.  P.  Byrne,  C.B.,  of  the  Home 
Office;  C.  E.  H.  Hobhouse;  Dr.  Needham,  one  of  the 
Commissioners  in  Lunacy;  H.  D.  Greene,  K.C. ; 
C.  E.  H.  Chadwyck-Healey,  K.C.;  the  Rev.  H.  N. 


24        MENTALLY  DEFICIENT  CHILDREN 

-  Burden,  Manager  of  Certified  Inebriate  Reformatories ; 
W.  H.  Dickinson,  at  that  time  Chairman  of  the 
National  Association  for  Promoting  the  Welfare  of 
the  Feeble-minded;  C.  S.  Loch,  Secretary  of  the 
Charity  Organisation  Society;  and  Mrs.  Hume  Pin- 
sent,  Chairman  of  the  Birmingham  Special  Schools 
Committee.  Subsequently  Dr.  Donkin,  one  of  H.M. 
Prison  Commissioners,  and  Dr.  J.  C.  Dunlop,  Super- 
intendent of  Statistics  in  the  Office  of  the  Registrar- 
General  for  Scotland,  were  added  to  the  Commission ; 
and  in  February,  1905,  the  Marquis  of  Bath  having 
resigned,  Lord  Radnor  was  appointed  Chairman. 

The  Commission  commenced  hearing  evidence  on 
November  14,  1904,  and  published  its  Report  on 
July  31,  1908.  The  248  witnesses  examined  included 
inspectors  and  medical  officers  of  special  schools, 
reformatories,  prisons,  lunatic  and  idiot  asylums, 
and  inebriate  homes,  and,  indeed,  "  representatives 
of  all  classes  of  persons  who  could  give  information 
on  the  subject  of  inquiry."  "  Full  particulars  "  were 
also  obtained  "of  the  manner  in  which  foreign 
countries  and  the  colonies  are  dealing  with  the  ques- 
tions submitted  in  the  original  reference."  Visits 
were  paid  to  "  various  institutions  in  which  pro- 
vision is  made  for  the  classes  of  persons  named  in 
the  reference  in  England  and  Wales,  Scotland  and 
Ireland,  and  on  the  .Continent."  In  addition,  five 
members  visited  the  United  States  of  America,  and 
issued  a  special  Report  of  their  observations.  Almost 
at  the  outset  it  was  found  that  "  there  were  no  avail- 
able statistics  from  which  any  trustworthy  estimate 
could  be  made  as  to  the  number  of  persons  who  might 
be  said  to  fall  within  one  or  other  of  the  categories 
named  in  our  reference.  We  decided,  therefore,  that 
an  expert  investigation  of  the  question  was  indis- 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     25 

pensable,  and  having  obtained  the  authority  of  the 
Treasury  for  the  expenditure,  which  was  necessarily 
considerable,  we  appointed  medical  investigators  to 
make  a  thorough  inquiry  in  regard  to  the  number  of 
mentally  defective  persons  (including  epileptics)  in 
sixteen  separate  typical  districts,  both  urban  and 
rural,  in  England  and  Wales,  Scotland  and  Ireland, 
in  the  hope  that,  from  the  particulars  thus  ascertained, 
we  might  be  able  to  form  at  least  a  rough  estimate 
of  the  whole  number,  and  of  the  provision  that  it 
would  be  necessary  to  make  for  their  proper  treat- 
ment." These  inquiries  by  medical  experts  were  a 
most  important  part  of  the  work  of  the  Commission, 
and  gave  their  conclusions  and  recommendations  a 
precision  and  authority  which  could  not  have  been 
obtained  in  any  other  way. 

The  Commissioners  published  their  Report  and 
evidence  in  eight  Blue-Books,  of  which  the  first  three 
contain  the  .evidence  on  the  original  reference,  and 
the  fourth  that  on  the  extended  reference.  The 
fifth  volume  consists  of  appendix  papers;  the  sixth 
contains  the  reports  of  the  medical  investigators ;  the 
seventh  the  report  on  the  visit  of  certain  Commis- 
sioners to  America;  while  the  eighth  contains  the 
Commissioners'  own  Reports  and  Recommendations. 

It  was  stated  in  the  Report  that  "  of  the  gravity 
of  the  present  state  of  things  there  is  no  doubt.  The 
mass  of  facts  that  we  have  collected,  the  statements 
of  our  witnesses,  and  our  own  personal  visits  and 
investigations,  compel  the  conclusion  that  there  are 
numbers  of  mentally  defective  persons  whose  train- 
ing is  neglected,  over  whom  no  sufficient  control  is 
exercised,  and  whose  wayward  and  irresponsible  lives 
are  productive  of  crime  and  misery,  of  much  injury 
and  mischief  to  themselves  and  to  others,  and  of  much 


26        MENTALLY  DEFICIENT  CHILDREN 

continuous  expenditure  wasteful  to  the  community 
and  to  individual  families. 

"  We  find  a  local  and  '  permissive  '  system  of 
public  education  which  is  available  here  and  there 
for  a  limited  section  of  mentally  defective  children, 
and  which,  even  if  it  be  useful  during  the  years  of 
training,  is  supplemented  by  no  subsequent  super- 
vision and  control,  and  is  in  consequence  often  mis- 
directed and  unserviceable.  We  find  large  numbers 
of  persons  who  are  committed  to  prisons  for  repeated 
offences,  which,  being  the  manifestations  of  a  per- 
manent defect  of  mind,  there  is  no  hope  of  repressing, 
much  less  of  stopping,  by  short  punitive  sentences. 
We  find  lunatic  asylums  crowded  with  patients  who 
do  not  require  the  careful  hospital  treatment  that 
well-equipped  asylums  now  afford,  and  who  might 
be  treated  in  many  other  ways  more  economically, 
and  as  efficiently.  We  find,  also,  at  large  in  the 
population  many  mentally  defective  persons,  adults, 
young  persons,  and  children,  who  are,  some  in  one 
way,  some  in  another,  incapable  of  self-control,  and 
who  are  therefore  exposed  to  constant  moral  danger 
themselves,  and  become  the  source  of  lasting  injury 
to  the  community." 

The  fundamental  recommendations  of  the  Commis- 
sion were  that  the  Lunacy  Commissioners  for  Eng- 
land and  Wales  should  be  replaced  by  a  larger  body, 
with  extended  powers  and  a  wider  purview,  to  be 
called  "  The  Board  of  Control/'  which  should  be 
responsible  for  the  proper  care  of  all  mentally  defec- 
tive persons.  This  central  authority  should  super- 
vise local  administration.  The  Local  Authority 
should  be  the  Council  of  each  County  and  County 
Borough,  and  they  should  be  required  by  Statute  to 
make  suitable  and  sufficient  provision  for  the  men- 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     27 


tally  defective.  They  should  exercise  their  powers 
through  a  Statutory  Committee,  to  be  called  the 
"  Committee  for  the  Care  of  the  Mentally  Defective," 
which  should  take  over  the  duties  of  the  Visiting 
Committee,  or  as  it  is  sometimes  called,  the  Asylums 
Committee,  of  the  County  Council. 

The  Report  of  the  Royal  Commission  excited  wide- 
spread interest  among  public  authorities  and  social 
workers  throughout  Great  Britain,  but  it  was  not 
until  considerable  pressure  had  been  put  upon  the 
Government,  and  two  private  Bills  on  the  subject  had 
been  introduced,  that  the  Home  Secretary  brought  in 
(on  May  16,  1912)  a  measure  to  give*  effect  to  its 
recommendations.  This  Bill  did  not  get  beyond  the 
Committee  stage  in  the  Session  of  1912,  but  was  re- 
introduced  in  1913,  and  received  the  Royal  Assent  on 
August  15.  In  England  and  Wales  it  came  into  opera- 
tion on  April  i,  1914;  the  corresponding  Act  for  Scot- 
land, which  comprised  also  amendments  of  the 
Scottish  Lunacy  Law,  came  into  operation  on  May  15, 
1914.  Those  who  desire  full  information  are  referred 
to  the  Mental  Deficiency  Acts  themselves,  prints  of 
which  may  be  obtained  from  Parliamentary  pub- 
lishers for  a  few  pence.  Our  space  will  permit  only 
a  brief  resume  of  the  principal  provisions,  more 
especially  those  relating  to  children. 

Taking  the  English  Act  first,  four  classes  of  persons 
who  are  mentally  defective  are  defined  to  be  defec- 
tives within  the  meaning  of  the  Act,  as  follows : 

"  (a)  Idiots — that  is  to  say,  persons  so  deeply  de- 
fective in  mind  from  birth  or  from  an  early  age  as 
to  be  unable  to  guard  themselves  against  common 
physical  dangers. 

"  (b)  Imbeciles — -that  is  to  say,  persons  in  whose 
case  there  exists  from  birth  or  from  an  early  age 


28        MENTALLY  DEFICIENT  CtiiLbREN 


mental  defectiveness  not  amounting  to  idiocy,  yet 
so  pronounced  that  they  are  incapable  of  managing 
themselves  or  their  affairs,  or,  in  the  case  of  children, 
of  being  taught  to  do  so. 

"  (c)  Feeble-minded  persons — that  is  to  say,  per- 
sons in  whose  case  there  exists  from  birth  or  from  an 
early  age  mental  defectiveness  not  amounting  to  im- 
becility, yet  so  pronounced  that  they  require  care, 
supervision,  and  control  for  their  own  protection  or 
for  the  protection  of  others,  or,  in  the  case  of  children, 
that  they  by  reason  of  such  defectiveness  appear  to 
be  permanently  incapable  of  receiving  proper  benefit 
from  the  instruction  in  ordinary  schools. 

"  (d)  Moral  imbeciles — that  is  to  say,  persons  who 
from  an  early  age  display  some  permanent  mental 
defect  coupled  with  strong  vicious  or  criminal  pro- 
pensities on  which  punishment  has  had  little  or  no 
deterrent  effect/' 

Though  all  persons  falling  under  the  above  cate- 
gories are  deemed  to  be  "  defectives  within  the  mean- 
ing of  the  Act,"  it  would  appear  from  Section  2  that 
they  only  become  subject  to  be  dealt  with  under  the 
Act,  (a)  if  under  twenty-one,  at  the  instance  of  the 
parent  or  guardian,  or  (6)  at  any  age  if  found  neg- 
lected, abandoned,  destitute,  or  cruelly  treated, 
criminal  or  inebriate,  or  being  the  pauper  mother  of 
an  illegitimate  child.  Defective  children  over  seven, 
notified  by  local  Education  Authorities  as  incapable 
of  receiving  benefit  or  further  benefit  in  special 
schools  or  classes,  or  detrimental  to  other  pupils  in 
such  schools,  or  certified  by  the  Board  of  Education 
on  account  of  special  circumstances  for  supervision 
or  guardianship,  are  also  liable  to  be  dealt  with  undei 
the  Act,  as  are  also  those  leaving  special  schools  or 
classes  "  in  whose  case  the  local  Education  Authority 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     29 


are  of  opinion  that  it  would  be  to  their  benefit  that 
they  should  be  sent  to  an  institution  or  placed  under 
guardianship/'  This  latter  provision  gives  valuable 
powers  for  securing  permanent  protection  for  those 
whose  home  conditions  would  militate  against  the 
improvement  effected  by  special  school  training 
being  retained  and  turned  to  account  in  after-life. 

It  will  be  seen  that  to  be  dealt  with  compulsorily 
under  this  Act  the  subject,  if  adult,  must  in  some 
way  have  been  brought  into  contact  with  existing 
law.  In  the  case  of  children  they  must  have  at 
least  been  found  liable  to  be  ordered  to  be  sent  to  a 
certified  Industrial  School,  or  have  proved  unfit  for 
instruction  in  a  special  school,  or  at  the  end  of  their 
term  there  have  proved  that  they  require  permanent 
care.  The  duty  of  ascertaining  what  children  over 
the  age  of  seven  and  under  the  age  of  sixteen  are 
defectives  devolves  on  the  local  Education  Authorities, 
all  of  whom  under  the  amended  Elementary  Educa- 
tion (Defective  and  Epileptic  Children)  Act  will  be 
called  on  to  notify  to  their  Local  Authorities  not  only 
the  names  of  those  passed  as  fit  subjects  for  educa- 
tion in  special  schools,  and  their  condition  when 
about  to  leave  these  schools,  but  also  the  names  of 
those  whom  idiocy  or  imbecility  renders  uneducable, 
and  consequently  requiring  to  be  dealt  with  under 
the  Mental  Deficiency  Act  by  way  of  supervision,  in 
an  institution,  or  under  guardianship.  Doubtful  cases 
are  to  be  referred  for  the  decision  of  the  Board  of 
Education.  The  efficiency  of  the  Mental  Deficiency 
Act,  so  far  as  children  are  concerned,  depends  largely 
upon  the  efficient  working  of  the  Education  Act 
referred  to.  Those  passed  for  special  schools  as 
"  mentally  defective  "  will  generally  fall  under  the 
definition  given  above  of  "  feeble-minded,"  but  will 


30        MENTALLY  DEFICIENT  CHILDREN 

only  become  "  defectives  "  to  be  dealt  with  under 
the  Mental  Deficiency  Act  when  reported  as  such  at 
the  end  of  their  school  career.  Thereupon  it  becomes 
the  duty  of  the  Local  Authority  to  deal  with  them  as 
may  seem  desirable,  either  by  supervision  at  their 
own  homes,  or  by  sending  them  to  suitable  institu- 
tions, or  by  placing  them  under  guardianship. 

The  Board  of  Control,  which  now  consists  of  the 
eight  former  paid  Commissioners  in  Lunacy,  with  two 
additional  Commissioners  specially  appointed  under 
the  Mental  Deficiency  Act,  and  a  paid  Chairman, 
together,  with  three  unpaid  Commissioners,  is  the 
Central  Authority  on  which  devolves  the  general 
supervision,  protection,  and  control  of  all  types  of 
defectives,  the  supervision  of  the  administration  by 
the  Local  Authorities  of  their  powers  and  duties 
under  the  Act,  the  licensing,  regulation,  and  inspection 
of  homes  and  institutions  of  all  classes  for  defectives, 
and  visitation  of  those  under  guardianship  or  under 
private  care,  and  the  provision  and  maintenance  of 
institutions  for  dangerous  defectives. 

The  Local  Authority  under  the  Act  is  the  County 
or  County  Borough  Council,  which  will  act  through 
a  specially  appointed  Committee  for  the  care  of  the 
mentally  defective,  consisting  either  of  (i)  members 
of  the  Council  (who  must  form  the  majority),  together 
with  non-Council  members  chosen  by  the  Council  for 
their  special  knowledge  and  experience  of  the  sub- 
ject, of  whom  some  must  be  women;  or  (2)  alterna- 
tively (at  the  discretion  of  the  Council)  the  Visiting 
or  Asylums  Committees  under  the  Lunacy  Acts,  with 
the  addition  of  at  least  two  women.  In  certain  cases 
approved  by  the  Home  Secretary  and  the  Local 
Government  Board  two  or  more  Local  Authorities 
may  combine  to  form  a  joint  Mental  Deficiency  Com- 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     31 


.  mittee.  Their  duties  and  powers  include  the  ascer- 
taining, except  in  the  case  of  those  dealt  with  at 
the  instance  of  their  parents  or  guardians  under  Sec- 
tion 2  (i)  (a),  of  what  persons  within  their  area  are 
defectives  subject  to  be  dealt  with  under  the  Act,  to 
provide  suitable  supervision  for  such  persons,  and, 
when  necessary,  to  place  them  in  institutions  or 
under  guardianship ;  to  provide  suitable  and  sufficient 
accommodation  for  such  persons  when  sent  to  certi- 
fied institutions  by  orders  under  the  Act ;  to  maintain 
them  wholly  or  in  part  in  institutions,  approved 
homes,  or  under  guardianship;  to  employ  the  officers 
necessary  for  carrying  out  the  Act;  and  to  make 
annual  and  such  other  Reports  as  may  be  required 
by  the  Board  of  Control.  Local  Authorities  are  not, 
however,  bound  to  expend  money  upon  the  above 
objects,  excepting  the  first,  unless  the  contribution 
by  Parliament  in  aid  amounts  to  50  per  cent,  of  the 
total  expenditure. 

In  addition  to  the  Local  Authorities,  Poor  Law 
Authorities  are  to  retain  the  same  powers  as  they 
previously  possessed  under  the  Poor  Law  to  deal  with 
pauper  defectives,  and  will  receive  the  same  grants 
as  they  were  entitled  to  under  the  Idiots  Act,  1886, 
notwithstanding  its  repeal. 

Four  classes  of  institutions,  etc.,  are  contemplated 
under  the  Act,  in  addition  to  approved  homes — -viz. : 

1.  State  Institutions  for  defectives  of  dangerous  or 
violent  propensities,  to  be  established  and  managed 
by  the  Board  of  Control. 

2.  Certified    Institutions,    established    by    Local 
Authorities,    benevolent    societies    (incorporated    or 
otherwise),  or  disinterested  individuals,  to  be  certi- 
fied, regulated,  and  inspected  by  the  Board,  and  to 
possess  powers  of  detention  under  conditions  laid 


32        MENTALLY  DEFICIENT  CHILDREN 


down  in  the  Act,   and  regulations   framed  by  the 
Home  Secretary. 

3.  Certified   Institutions    provided   by    Poor   Law 
Guardians,  and  approved  by  the  Board  of  Control, 
subject  to  the  same  conditions  as  above. 

4.  Certified  Houses,  established  by  individuals  for 
private  profit,  approved  by  the  Board  of  Control,  but 
not  eligible  for  defectives  towards  whose  expenses 
there  is  a  Parliamentary  grant.     These  also  have 
powers  of  detention. 

Under  the  title  of  "  Approved  Homes/'  premises 
wherein  defectives  are  received  and  supported  wholly 
or  partly  by  voluntary  contributions,  or  by  applying 
the  excess  of  payments  of  some  patients  for  or 
towards  the  support  of  other  patients,  and  any 
similar  establishment  run  for  private  profit,  may  be 
approved  by  the  Board  under  such  conditions  as  they 
may  think  fit.  Such  homes  cannot  receive  defectives 
legally  committed  to  an  institution,  and  have  no  legal 
power  of  detention. 

Elaborate  Regulations,  which  are  already  in  force, 
have  been  issued  by  the  Home  Secretary  in  pursuance 
of  the  Act  under  the  title  of  "  Provisional  Regula- 
tions/'* These  describe  in  detail  the  duties  of  Local 
Authorities,  the  procedure  on  petitions,  and  the  grant- 
ing, transfer,  renewal,  revocation,  and  resignation  of 
certificates  for  certified  institutions  and-  certified 
houses.  They  give  rules  for  approvals  of  homes,  and 
the  management  of  certified  institutions,  certified 
houses,  and  approved  homes,  and  also  for  the  inspec- 
tion of  these  institutions  and  houses.  Forms  of  peti- 
tions, statutory  declarations,  orders,  certificates,  etc., 

*  To  be  obtained  from  Wyman  and  Sons,  29,  Bream's 
Buildings,  Fetter  Lane,  E.G.,  and  other  Parliamentary  pub- 
lishers, price^Jd. 


DEFECTIVE  AND  EPILEPTIC  CHILDREN     33 


are  appended.  Space  does  not  permit  even  a  brief 
summary  of  these.  It  must  suffice  to  state  that 
ample  precautions  are  taken  to  insure  the  suitability 
for  their  respective  purposes  of  the  various  types  of 
institutions,  and  by  means  of  reports,  records,  and 
frequent  official  inspections,  to  safeguard  the  suitable 
and  humane  treatment  of  the  inmates,  and  to  prevent 
detention  when  not  justified  by  the  mental  condition. 
For  admission  to  all  the  establishments,  other  than 
approved  homes,  -two  medical  certificates,*  one  of 
which  must  be  by  a  practitioner  approved  by  the 
Local  Authority  or  the  Board  of  Control  for  the  pur- 
pose, are  required,  and  in  addition  a  judicial  order  in 
the  case  of  any  person  not  certified  either  as  idiot  or 
imbecile.  It  is  only  in  the  latter  cases  that  a  state- 
ment of  particulars  can  be  signed  by  other  persons 
than  the  father  or  mother — -i.e.,  by  a  person  under- 
taking the  duties  of  guardian  towards  the  patient. 
It  must  be  remembered  that  the  Idiots  Act,.  1886, 
having  been  repealed,  the  simple  procedure  by  one 
medical  certificate  is  no  longer  available,  even  in  the 
case  of  idiots  and  imbeciles.  As  regards  approved 
homes  (presumably  for  border-line  cases),  though  ad- 
mission certificates  are  not  prescribed,  it  seems  likely 
that  full  particulars  of  the  bodily  and  mental  condi- 
tion of  inmates  will  have  to  be  reported  by  the 
Medical  Officer. 

The  Mental  Deficiency  and  Lunacy  (Scotland)  Act, 
1913,1  is  a  counterpart  of  the  English  Act,  with  cer- 
tain modifications  adapting  it  to  Scottish  administra- 
tion, and  a  few  amendments  of  Scottish  Lunacy  Law. 

*  Form  of  Medical  Certificate  is  printed  in  Appendix  E, 
p.  264. 

t  To  be  obtained  from  Wyman  and  Sons,  Ltd.,  Fetter  Lane, 
E.G.;  or  H.M.  Stationery  Office,  23,  Forth  Street,  Edinburgh. 

3 


34        MENTALLY  DEFICIENT  CHILDREN 

In  Part  I.  the  expression  "  School  Board  "  takes  the 
place  of  "  Education  Committee  "  so  far  as  ascertain- 
ing what  children  are  defectives,  and  which  of  such 
children  are  educable  in  special  schools,  and  making 
suitable  provision  for  the  education  or  proper  care  of 
such  children  between  five  and  sixteen  years  of  age 
when  the  parents  or  guardians  are  unable  to  do  so; 
they  must  notify  to  the  Parish  Council  and  the 
General  Board  of  Control  the  names  of  such  children 
as  are  incapable  of  receiving  benefit  or  further  benefit 
from,  or  are  otherwise  unsuitable  for,  special  schools 
or  classes.  The  Parish  Council  is  the  Local  Authority 
responsible  for  the  care  and  supervision  of  such 
reported  children,  and  also  for  ascertaining  what 
persons  of  sixteen  years  or  over  are  defectives  subject 
to  be  dealt  with  under  the  Act,  otherwise  than  at  the 
instance  of  their  parents  or  guardians,  and  for  taking 
steps  that  they  shall  be  dealt  with  by  being  sent  to 
institutions  or  placed  under  guardianship.  Upon  the 
Sheriff  devolves  the  duty  of  making  judicial  orders 
when  these  are  required. 

The  General  Board  of  Control  for  Scotland  now 
consists  of  three  paid  Medical  Commissioners  (in- 
cluding the  two  formerly  known  as  Lunacy  Commis- 
sioners), in  addition  to  the  Chairman  and  two  legal 
members,  and  of  four  Medical  Deputy-Commissioners, 
one  of  the  latter  being  a  woman.  Two  others  may, 
if  necessary,  be  appointed.  A  District  Lunacy  Board 
will  in  future  be  known  as  the  District  Board  of 
Control.  If  it  comprises  six  elected  women  members, 
not  more  than  two  women  must  be  co-opted.  Their 
duties  will  be  similar  as  regards  carrying  out  this  Act 
to  those  of  County  and  County  Borough  Councils  in 
England. 


CHAPTER  III 
SPECIAL  INSTRUCTION 

FROM  the  preceding  chapter  it  will  be  seen  that  con- 
siderable attention  has  been  given  in  England  of  late 
years  to  the  class  of  subnormal  persons  who  are 
called  in  this  country  feeble-minded,  in  distinction  to 
the  imbecile  and  idiot  groups.  Recent  legislation  has 
taken  account  of  them  from  the  sociological  stand 
point  in  the  Mental  Deficiency  Act,  and  from  the 
scholastic  in  the  1899  and  1914  Acts  for  the  Education 
of  Defective  and  Epileptic  Children.  In  the  first  they 
are  referred  to,  under  the  definition  of  feeble-minded 
persons,  as  children  who  by  reason  of  mental  defec- 
tiveness,  not  amounting  to  imbecility,  existing  from 
birth  or  from  an  early  age,  "  appear  to  be  permanently 
incapable  of  receiving  proper  benefit  from  the  instruc- 
tion in  ordinary  schools/'  In  the  latter  they  are 
referred  to  as  "  children  not  being  imbecile,  and  not 
being  merely  dull  or  backward — that  is  to  say,  chil- 
dren, by  reason  of  mental  or  physical  defect,  incapable 
of  receiving  proper  benefit  from  the  instruction  in  the 
ordinary  public  elementary  schools,  but  not  incapable 
by  reason  of  such  defect  of  receiving  benefit  from 
instruction  in  special  classes  or  schools."  It  is  to 
be  remarked  that  the  element  of  permanence  appears 
in  the  first  definition,  but  not  in  the  second;  and  it 
may  be  argued  therefrom  that  the  special  schools  can 
reasonably  be  regarded  as  means  of  determining  such 

35 


36        MENTALLY  DEFICIENT  CHILDREN 

permanence,  especially  in  relation  to  the  need  for 
segregation.  It  will  also  be  noted  that  the  term 
"  mental  defect/'  as  used  in  the  Mental  Deficiency 
Act,  has  a  wider  connotation  than  in  the  Education 
Acts,  where  it  embraces  only  one  of  the  four  classes 
covered  by  the  former — viz.,  that  of  "  feeble-minded. " 
With  the  judicious  administration  of  the  new  Acts 
it  is  hoped  that  Great  Britain  will  stand  ahead  of  all 
other  countries  in  its  treatment  of  the  mentally  defec- 
tive class.  It  must,  however,  be  admitted  that  in 
the  past  German  and  Scandinavian  countries  have 
been  in  advance  of  us  in  organising  practical  arrange- 
ments for  the  training  of  exceptional  children.  So 
far  back  as  1863  there  was  established  at  Halle  an 
auxiliary  class  (Hilfsklasse)  for  pupils  found  incapable 
of  following  the  ordinary  elementary  school  curricu- 
lum; in  1867  a  similar  class  was  established  at  Dres- 
den. Leipsic  and  Brunswick  followed,  and  gradually 
auxiliary  schools  (Hilfschulen)  grew  out  of  these 
classes.  Herr  Kielhorn,  the  director  of  the  Bruns- 
wick auxiliary  school  (established  in  1881),  gave  an 
account  in  1894  of  32  auxiliary  schools,  consisting  of 
no  classes,  with  a  teaching  staff  of  115,  established 
in  various  parts  of  Germany.  Herr  Wintermann,* 
of  Bremen,  supplemented  this  statement  in  1898 
by  the  information  that  at  that  date  auxiliary  schools 
existed  in  52  German  towns,  consisting  of  202  classes, 
and  containing  4,281  children  (2,400  boys,  1,881  girls) 
under  instruction  by  225  teachers.  So  rapid  was  the 
development  that  at  the  end  of  1905  Fraulein  Dora 
Weinrich,  of  the  Centrale  fiir  Private  Fursorge,  Frank- 
fort-on-Main,  in  her  paper  at  the  After-care  Confer- 
ence at  Nottingham,  said  there  were  230  special 

*  Berichten  uber  den  ersten    Verbandstag  der  Hulfschulen 
Deutschlands,  1898. 


SPECIAL  INSTRUCTION  37 


schools,  with  15,000  pupils,  and  that  the  aim  was  to 
have  at  least  one  in  every  town  of  15,000  inhabitants. 
It  is  claimed  that  many  children  considered  hopeless 
in  the  ordinary  schools  have  been  enabled  by  the 
special  instruction  given  them  to  follow  useful  prac- 
tical careers.  The  large  extension  of  the  auxiliary 
schools  above  noted  is,  in  a  practical  country  like 
Germany,  perhaps  the  best  testimony  to  their  success. 
In  the  Scandinavian  countries  also,  in  addition  to 
the  boarding  establishments  for  imbeciles  previously 
described,  day  classes  for  the  instruction  of  "  abnormal 
children  "  have  been  established  for  more  than  thirty 
years.  In  Christiania  and  Bergen  they  were  started 
under  the  direction  of  Herr  Karl  Lippestad  and  of 
Herr  Soethre  respectively.  In  addition,  separate 
classes  for  merely  backward  (not  necessarily  defec- 
tive) children  were  organised  in  connection  with  two 
of  the  largest  elementary  schools  in  Bergen.  In  Den- 
mark various  grades  of  defectives  are  received  either 
in  day  classes  or  in  residential  institutions,  as  may 
be  necessary,  in  the  chain  of  establishments  organised 
and  supervised  by  Dr.  Keller,  which  have  now  been 
adopted  by  the  State.  The  arrangements  for  instruc- 
tion are  very  complete,  and  the  ratio  of  teachers  to 
taught  liberal,  the  classes  usually  consisting  of  not 
more  than  eight  or  ten  pupils.  Stress  is  laid  upon 
physical  and  manual  exercises.  The  pupils  not  fit 
to  return  home  after  school  training  are  drafted  to 
working  institutions,  of  which  there  are  several  grades. 
Farm  work  and  other  occupations,  such  as  brush, 
broom,  and  basket  making,  are  followed  by  the  older 
boys.  The  older  girls  are  employed  in  dairy  and 
laundry  work,  as  well  as  in  a  variety  of  home  in- 
dustries, such  as  weaving  cloth  for  dresses,  curtain 
material,  etc.  For  some,  situations  in  domestic  and 


38        MENTALLY  DEFICIENT  CHILDREN 


dairy  service  are  found,  and  it  is  said  of  the  girls, 
whose  careers  are  carefully  watched,  that  "  very  few 
turn  out  badly/'  Professor  Keller  has  kindly  sup- 
plied us  with  a  list  of  institutions,  public  and  private, 
existing  in  Denmark,  Norway,  Sweden,  and  Finland, 
from  which  it  appears  that  no  less  than  forty-three 
establishments  for  the  care  of  mental  defectives  have 
been  established  in  these  countries,  with  an  aggregate 
accommodation  for  about  1,500  improvable  and  600 
unimprovable  cases. 

In  Belgium  special  schools  for  the  mentally  defec- 
tive were  in  existence  for  some  years  previous  to  the 
war,  and  in  Brussels,  Antwerp,  and  Ghent,  there  were 
also  After-care  Societies,  which  originated  from  the 
"  Societe  Protectrice  de  FEnfance  Anormale."  The 
movement  in  favour  of  "  special  schools  "  for  sub- 
normal children  has  also  spread  to  Austria,  to  Switzer- 
land, to  France,  and  even  to  Spain.  In  Italy  there 
exists  a  "  National  League  for  the  Protection  of  De- 
ficient Children,"  under  the  presidency  of  Signer 
Guido  Baccelli,  formerly  Minister  of  Public  Instruc- 
tion, one  of  the  first-fruits  being  the  opening  in  Rome 
of  a  day-school.  In  America  much  important  work 
has  been  done.  The  members  of  the  Commission  on 
the  Care  and  Control  of  the  Feeble-minded  who 
visited  that  country  were  favourably  impressed  by 
what  they  saw  in  some  of  the  States,  for  it  must  be 
remembered  that  each  State  has  its  own  regulations 
and  institutions.  Our  Commissioners  were  struck  by 
the  excellent  practical  work  they  saw  being  done  by 
the  feeble-minded,  and  also  by  the  economical  char- 
acter of  the  buildings  and  arrangements  generally. 
There  are  in  America  several  industrial  colonies  for 
permanent  care.  These  have  been  recognised  as 
essential.  Work  in  the  special  schools  is  regulated 


SPECIAL  INSTRUCTION  39 

with  this  view,  and  to  the  continuous  training  and 
supervision  is  no  doubt  largely  due  the  excellent  work 
done  by  some  of  the  adult  feeble-minded.     Our  Com- 
missioners gave  a  specially  interesting  account  of 
what  they  saw  at  the  Templeton  Colony  for  Feeble- 
minded   Males,    ninety    miles    from    Boston.     The 
colonists  "  are  all  required  to  do  manual  work,  and 
many  of  them  do  nearly  the  full  work  of  a  free 
labourer.     We   saw   a   group   of   four,    with   heavy 
sledges  and  hammers,  breaking  rock  and  drilling  it 
for   blasting   with   explosives.     They   were   working 
steadily  and  without  supervision.     Farther  on  was 
another  group  of  five  men  working  in  a  field.     They 
were  bringing  in  stocks  of  corn,   which  they  were 
loading  upon  a  cart.     Others  in  the  shed  were  un- 
loading and  storing  the  corn.     A  further  group  was 
hauling  brick  in  wheelbarrows.     At  a  little  distance 
there  was  a  row  of  about  a  dozen,  who,  under  the 
supervision  of  one  man  only,  were  working  a  field 
with   sharp   pickaxes.     An   imbecile   was   ploughing 
with  a  pair  of  horses,  his  daily  task.     All  of  these  men 
had  come  from  Dr.  Fernald's  schools  for  the  feeble- 
minded, and  a  large  proportion  of  those  who  were 
busily  and  happily  engaged  in  useful  work  could 
never  be  taught  to  read  and  write;  some  had  not 
human  speech.     The  previous  training  was,  of  course, 
essential ;  idiots  and  low-grade  imbeciles  could  not  be 
employed  in  this  way  without  preliminary  training/' 
In  England  priority  in  the  opening  of  a  Special 
Class  belongs  to  Leicester,  where  the  School  Board 
started  one  in  April,  1892.     In  the  same  year  were 
established  in  London  "  Schools  for  Special  Instruc- 
tion "   qf  children  who,   by  reason  of  physical  or 
mental  defects,  could  not  be  properly  taught  in  the 
ordinary   standards   or  by   ordinary   methods,    Mrs. 


40        MENTALLY  DEFICIENT  CHILDREN 


Burg  win  being  appointed  organising  superintendent. 
Under  her  able  direction,  ninety-five  centres  of  special 
instruction  for  mentally  defective  children  have  up 
to  the  present  time  been  established,  chiefly  in  the 
poorer  districts  of  the  Metropolis,  with  an  attendance 
roll  of  7,848  pupils — a  number  constantly  increasing. 
The  Board  have  wisely  ordained  that  no  more  than 
twenty  children  be  assigned  to  each  teacher;  in  prac- 
tice the  classes  are  even  smaller.  The  ratio  of  pupils 
is,  however,  much  larger  than  that  which  obtains  in 
the  Scandinavian  schools,  where  one  teacher  is  pro- 
vided for  every  ten  pupils;  but  the  superintendent 
utilises  to  the  utmost  the  teaching  force  at  her  com- 
mand by  well-devised  time-tables.*  It  may  be  re- 
marked with  regard  to  this  that,  though  the  ordinary 
school  nomenclature  of  studies  is  retained  (as  in  the 
case  of  the  so-called  "  three  R's  "),  much  more  than 
the  ordinary  instruction  is  included,  sensorial  and 
manual  training  and  objective  methods  of  demonstra- 
tion being  freely  employed.  The  "occupations/' 
which  form  an  important  part  of  each  day's  work, 
are  specially  adapted  to  the  varying  capacities  of 
individual  pupils.  The  results,  as  evidenced  at 
annual  exhibitions  of  the  products  of  manual  training 
in  the  London  Council  Schools  generally,  are  most 
encouraging,  and  in  some  cases  surprising.  It  may 
be  stated,  indeed,  that  at  these  exhibitions  the  array 
of  work  by  children  in  the  special  classes  creditably 
holds  its  own,  side  by  side  with  that  of  the  normal 
children.  During  the  last  ten  years  an  advance  has 
been  made  by  the  establishment  of  twelve  centres  for 
about  1,300  "  Elder  Boys/'  in  which  instruction  is 
given  in  manual  arts  by  male  teachers.  Four  centres 
for  360  "  Elder  Girls  "  have  also  been  established. 

*   See  specimen  time-table,  Appendix  D,  p.  262-3. 


SPECIAL  INSTRUCTION  41 


The  selection  of  pupils  for  these  classes  is  made  by 
medical  officers  appointed  for  the  purpose  in  conjunc- 
tion with  the  Superintendent  of  Special  Instruction. 
The  parents,  and  also  the  family  doctor,  may  attend 
the  examination;  but  we  shall  not  discuss  here  the 
mode  of  procedure,  as  we  have  devoted  a  special 
chapter  (Chapter  VII.)  to  this  subject. 

The  Report  of  the  Chief  Medical  Officer  of  the 
Board  of  Education  for  1915  states  that  up  to  July  31, 
1914,  the  number  of  certified  schools  for  mentally 
defective  children  in  England  and  Wales  was  184, 
with  accommodation  for  14,555  children,  and  a  total 
average  of  13,563  on  the  register.  These  include 
eleven  residential  schools,  providing  accommodation 
for  902  children  on  the  register.  The  present  Report 
stated  that  177  out  of  317  education  authorities  had 
taken  action  under  the  Act,  and  upwards  of  fifty 
authorities  had  themselves  established  schools.  The 
Royal  Commission  estimated  the  number  of  children 
in  England  and  Wales  needing  provision  at  35,662. 
About  two-fifths  of  this  number  are  being  dealt  with 
at  the  present  time  in  certified  special  schools,  and 
the  Chief  Medical  Officer  of  the  Board  of  Education 
considers  that  the  aggregate  accommodation  necessary 
for  educable  mental  defectives,  excluding  idiots  and 
imbeciles,  amounts  to  about  25,000  school  places. 

There  is,  unfortunately,  sometimes  prejudice  in 
the  minds  of  parents  against  the  attendance  of  their 
children  at  special  schools,  as  stamping  them  with 
inferiority.  The  Act  of  1899  recognises  parental 
rights  in  Subsection  5  of  Section  2,  which  compels 
school  authorities  to  "  make  provision  for  the  ex- 
amination from  time  to  time  of  any  child  dealt  with 
under  this  section,  in  order  to  ascertain  whether  such 
child  has  attained  such  a  mental  and  physical  con- 


42         MENTALLY  DEFICIENT  CHILDREN 

dition  as  to  be  fit  to  attend  the  ordinary  classes  of 
public  elementary  schools,"  and,  if  the  parents  so 
request,  re-examination  must  be  made  at  intervals 
of  not  less  than  six  months.  The  amending  Act  of 
1914  further  provides  for  the  parents  being  consulted 
by  the  Local  Education  Authority  on  the  subject  of 
suitable  provision  for  the  mentally  defective  child, 
which,  if  not  made  by  the  parents,  must  be  provided 
by  the  authority  either  in  a  special  day  school  or 
class,  or  in  a  special  residential  school.  The  parents 
are  to  have  a  certain  choice  in  the  selection  of  the 
former,  and  the'r  written  consent,  which  must  not  be 
unreasonably  withheld,  is  necessary  before  sending 
the  child  to  a  boarding-school. 

Education  Committees  have  made  provision  for  the 
periodical  examination  by  the  medical  officers  of  ajl 
children  attending  the  special  classes.  On  their 
report,  which  is  based  to  a  large  extent  on  informa- 
tion as  to  progress  furnished  by  the  "  special  " 
teachers,  improved  cases  are  sent  back  to  the  ordinary 
elementary  schools.  In  view  of  the  fact  that  under 
the  Mental  Deficiency  Act  (Section  2,  2)  notice  will 
have  to  be  given  by  the  Education  Authority  to  the 
Local  Authority  of  all  defective  children  over  the  age 
of  seven,  (i)  who  have  been  ascertained  to  be  in- 
capable of  receiving  benefit  or  further  benefit  in 
special  schools  or  classes,  or  who  are  detrimental  to 
the  other  children  in  those  classes,  or  (2)  who  on  or 
before  attaining  the  age  of  sixteen  are  about  to  be 
withdrawn  or  discharged  from  such  classes,  and  re- 
quire care  in  an  institution  or  under  guardianship,  it 
is  important  that  the  first  and  subsequent  examina- 
tions should  be  conducted  with  precision  on  a  definite 
plan.  An  elaborate  scheme  for  this  has  therefore 
been  drawn  up  by  the  Board  of  Education. 


SPECIAL  INSTRUCTION  43 


There  are  a  few  educational  homes  which  receive 
children  of  the  better  social  class  who  are  so  far 
deficient  or  irregular  in  mental  development  as  to 
require  special  education.  As  the  mental  deficiency 
or  irregularity  is  often  intimately  connected  with 
physical  abnormality,  skilled  medical  supervision  is  an 
advantage.  It  is  obvious  that  a  child  whose  mental 
deficiency  or  nervous  peculiarity  is  but  slight  will 
have  a  better  chance  of  improvement,  when  educated 
with  those  of  similar  mental  calibre,  than  if  subjected 
to  hopeless  competition  with  normal  children  at  an 
ordinary  school,  or,  on  the  other  hand,  exposed  to  the 
depressing  influences  of  an  institution  where  idiots  are 
received.  Such  private  establishments  are  now  sub- 
ject to  the  approval  and  visitation  of  the  Board  of 
Control. 

In  addition  to  arrangements  organised  by  Educa- 
tion Committees,  certain  philanthropic  agencies  have, 
since  1890,  established  industrial  homes  in  various 
parts  of  the  country  for  the  employment,  under 
judicious  supervision,  of  feeble-minded  adolescents. 
In  a  few  instances  there  have  also  been  established 
institutions  for  the  training  of  younger  children  for 
whom  a  boarding-school  is  essential,  either  on  account 
of  immoral,  vicious,  or  truant  tendencies,  or  because 
they  come  from  very  bad  homes.  In  1896  the 
National  Association  for  Promoting  the  Welfare  of 
the  Feeble-minded  was  formed,  with  the  object  of 
co-ordinating  the  scattered  efforts  that  had  already 
been  made,  and  arousing  a  larger  share  of  public 
interest.  It  has  under  its  immediate  control  in  the 
neighbourhood  of  the  Metropolis  three  homes,  two 
for  girls  beyond  school  age,  and  one  for  feeble-minded 
mothers  and  their  children,  and  has  established,  under 
the  patronage  of  H.R.H.  the  Princess  Christian,  an 


44       MENTALLV  DEFICIENT  CHILDREN 


Endustrial  Colony  in  Kent,  where  over  200  boys  and 
girls  and  adults  are  at  present  resident.  They  are 
accommodated  in  scattered  buildings  on  various  parts 
of  the  estate  of  170  acres,  the  males  being  employed 
principally  in  farm  work,  and  also  in  carpentering, 
shoemaking,  etc.,  and  the  females  in  domestic,  dairy, 
and  laundry  work. 

In  May,  1902,  the  Incorporated  Lancashire  and 
Cheshire  Society  for  the  Permanent  Care  of  the 
Feeble-minded  opened  a  boarding-school  for  boys  at 
Sandlebridge,  near  Manchester,  and  in  September  of 
the  same  year  a  home  for  girls,  all  under  the  manage- 
ment of  Miss  Mary  Dendy.  In  the  first  instance, 
12  boys  and  8  girls  were  admitted.  In  September, 
1914,  there  were  161  boys  under  care,  102  of  them 
being  under  sixteen,  and  59  over  sixteen,  years  of  age; 
and  104  girls,  of  whom  53  were  under,  and  51  over, 
sixteen.  Children  are  not  admitted  over  thirteen,  and 
as  far  as  possible  are  kept  for  life;  42  boys  work  on 
the  farm  and  garden,  and  52  girls  are  employed  in  the 
laundry  and  the  various  houses. 

In  May,  1907,  the  Sandwell  Hall  Boarding-school 
for  the  Feeble-minded  was  opened  near  Birmingham 
by  the  generous  efforts  of  the  Rev.  H.  N.  Burden,  one 
of  the  members  of  the  Royal  Commission  on  the  Care 
and  Control  of  the  Feeble-minded.  Sandwell  Hall  was 
formerly  the  family  seat  of  the  Earls  of  Dartmouth, 
and  stands  in  the  midst  of  a  spacious  park  a  few 
miles  north  of  Birmingham.  In  this  institution 
special  arrangements  were  made  for  training  in  prac- 
tical work — gardening,  carpentry,  boot-making,  brush- 
making,  laundry  work,  carpet-weaving,  and  tailoring. 
The  full  complement  of  200  was  soon  received.  At 
first  both  boys  and  girls  were  admitted,  but  the  girls 
have  since  been  transferred,  and  Sandwell  is  now 


SPECIAL  INSTRUCTION  45 

reserved  for  boys  only.  No  cases  are  retained  after 
sixteen,  but  whenever  possible  they  are  drafted  on 
to  other  institutions.  Mr.  Burden's  energy  and  enter- 
prise have,  however,  extended  far  beyond  the  limits 
of  Sandwell  Hall,  with  the  result  that  Sandwell  is 
now  merely  one  of  a  group  of  institutions,  called  the 
"  National  Institutions  for  Persons  requiring  Care 
and  Control/'  The  central  offices  of  the  Incorporation 
are  at  14,  Howick  Place,  Westminster.  The  institu- 
tions are  intended  for  "permanent  as  distinct  from 
temporary  care,  and  no  case  is  knowingly  received  as 
a  temporary  measure."  They  include  Stoke  Park 
Colony,  near  Bristol,  opened  in  1908,  and  now  cer- 
tified by  the  Board  of  Control  as  an  "  institution  " 
for  750  male  and  female  cases,  under  the  Mental 
Deficiency  Act,  and  also  certified  by  the  Home  Office 
under  the  Children  Act  as  a  Special  School  for 
mentally  defective  children;  the  Midland  Counties 
Institution,  Whittington  Hall,  Chesterfield,  certified 
by  the  Board  of  Control  for  320  female  cases;  and  the 
Eastern  Counties  Institution,  East  Harling,  Norfolk, 
certified  by  the  Board  of  Control  for  330  male  cases. 
The  Royal  Victoria  Home  near  Bristol  and  Clevedon 
Hall  in  Somersetshire  are  registered  as  "  ancillary" 
to  Stoke  Park,  and  the  latter  is  intended  partly  for 
the  use  of  those  members  of  the  staff  and  inmates  of 
the  other  houses  who  require  change  and  special 
treatment,  and  partly  for  the  training  of  specially 
selected  girls  with  very  slight  mental  defect,  who 
may  ultimately  become  fit  for  domestic  service  in 
better-class  situations. 

In  May,  1908,  the  three  Boards  of  Guardians  then 
responsible  for  the  city  of  Birmingham — namely,  the 
Aston,  Birmingham,  and  King's  Norton  Boards — 
opened  the  Monyhull  Colony  near  Birmingham  for 


46        MENTALLY  DEFICIENT  CHILDREN* 

Epileptic  and  Feeble-minded  Persons,  which  has  been 
described  in  Chapter  I. 

Altogether  there  are  now  in  England  a  considerable 
number  of  homes  of  this  class,  particulars  of  which 
will  be  found  in  Appendix  A.  The  accommodation  so 
far  available,  however,  is  inadequate  to  deal  with  the 
large  number  of  cases  in  need  of  provision.  All  such 
institutions  have  a  long  waiting  list,  and  many  Com- 
mittees for  the  Care  of  the  Mentally  Defective  who 
have  taken  up  their  duties  under  the  Mental 
Deficiency  Act  have  found  that  they  must  establish 
institutions  of  their  own  to  provide  the  accommoda- 
tion they  require. 


A  few  illustrative  cases,  giving  an  idea  of  the  class 
of  children  to  whom  the  designation  of  "  feeble- 
minded "  may  appropriately  be  applied,  will  help  to 
elucidate  the  subject: 

PRIVATE  CASES. 

CASE  I. — A  child  of  highly  intellectual  parents  is 
noted  to  be  somewhat  delicate  in  babyhood,  but  no 
suspicion  of  mental  abnormality  is  entertained  by  his 
parents  until,  at  two  years  of  age,  it  is  found  he  uses 
only  a  few  monosyllabic  words,  and  does  not  try  to 
construct  sentences  for  himself,  though  he  can  perfectly 
well  repeat  what  is  said  to  him.  He  frequently,  indeed, 
repeats  questions  put  to  him  instead  of  replying  to  them, 
thus  showing  that  the  defect  is  not  one  of  hearing,  but 
of  understanding.  Much  care  and  patience  is  exercised 
by  an  intelligent  mother,  with  the  result  that  at  four 
he  speaks  fairly  well,  though  with  thick  utterance. 
Home  education  is  carried  on  till  he  is  seven  years  of 
age,  but  a  brother  two  years  younger  is  almost  two 


SPECIAL  INSTRUCTION  47 


years  in  advance  of  him  in  elementary  studies.  He  is 
then  sent  to  a  kindergarten  for  morning  lessons;  he 
takes  interest  in  the  songs  and  in  simple  musical  drill, 
does  paper-folding,  stick-laying,  mat -weaving,  and  bead- 
threading  in  series  of  number  and  colour.  His  interest, 
however,  soon  flags,  and  he  is  apt  to  repeat  the  same 
question  again  and  again,  as  if  not  attending  to  the 
answer.  In  calculation  he  makes  but  little  progress, 
and  with  difficulty  masters  the  simple  rules  of  arith- 
metic. By  dint  of  individual  instruction  he  attains, 
by  the  time  he  is  ten  years  of  age,  the  power  of  reading, 
though  in  a  monotonous  style,  easy  stories  in  a  primer, 
writes  copies  in  text-hand,  and  plays  simple  exercises 
on  the  piano.  There  is,  however,  still  a  marked  childish- 
ness of  manner,  a  thick  articulation  and  staccato  utter- 
ance, and  a  tendency  to  repeat  questions  in  a  meaningless 
way.  His  bodily  development  has  improved,  and  his 
only  sensory  defect  is  an  error  of  refraction  corrected  by 
spectacles.  Some  twitching  movement  is  noticeable 
in  the  muscles  of  the  fingers,  especially  under  excite- 
ment; but  otherwise  muscular  control  is  fairly  good. 
Under  drill,  regulated  muscular  exercise,  manual  training, 
and  varied  but  brief  school  lessons,  considerable  im- 
provement is  proceeding,  and  he  is  a  steady  worker  in 
garden,  and  good  at  Sloyd  work.  (He  is  now  learning 
practical  farming.) 

CASE  II. — A  pretty,  well-nourished  little  girl  of  five, 
the  third  child  of  healthy,  intelligent  parents. 

Type. — Mongolian . 

The  family  history  records  nothing  unfavourable. 

History. — As  a  baby  she  was  not  able  to  suck,  and 
was  therefore  brought  up  with  great  difficulty  on  a 
bottle.  She  could  not  walk  or  talk  till  four  years  of 
age. 

On  examination,  she  is  able  to  count  to  20,  and  has 
a  good  memory.  She  has  some  hypermetropic  astig- 
matism, for  which  glasses  are  prescribed. 

On  examination  at  eight  years  of  age,  she  reads  easy 
words  and  writes  a  little;  she  recognises  animals  in 


48        MENTALLY  DEFICIENT  CHILDREN 

pictures,  and  can  count  up  to  100,  but  cannot  calculate 
at  all.  She  can  almost  dress  herself,  and  is  useful  in 
the  house.  The  only  trouble  is  weak  powe  of 
attention . 

A  year  later  she  was  able  to  write  a  short  letter  from 
dictation,  and  was  improving  in  every  way. 

CASE  III. — A  stupid -looking  youth  of  eighteen ;  height, 
5  feet  loj  inches. 

Family  History. — The  father  died  at  forty-five  of  pneu- 
monia. The  paternal  grandfather,  who  had  been  in  the 
army,  was  a  heavy  drinker;  he  died  at  seventy-two, 
having  done  no  work  for  the  last  twenty-five  years  of 
his  life. 

On  examination,  he  is  found  to  be  a  high-grade  defec- 
tive of  no  special  type.  He  has  a  small  forehead  and  a 
defective  occiput;  the  little  ringers  are  abnormally 
short,  and  he  is  flat-footed.  He  reads  the  newspaper, 
can  write  and  perform  simple  calculations.  He  knows 
the  day  of  the  week  and  the  year,  but  not  what  month 
it  is;  he  does  not  know  the  name  of  the  King,  though 
he  can  say  who  the  last  King  was. 

The  History  is  that  he  was  precocious  as  a  child,  and 
not  considered  abnormal  till  he  left  the  infant  school, 
when  he  was  found  to  be  dull  at  learning.  He  was, 
however,  very  mischievous  and  imaginative.  At  thir- 
teen years  of  age  he  was  only  in  Standard  IV.  The 
parents  were  advised  that  work  would  bring  him  out,  so 
he  was  sent  to  a  cabinet-maker's.  After  a  few  months 
he  was  sent  home  as  having  no  adaptability.  He  got 
another  place  as  an  errand-boy,  but  nothing  could  be 
made  of  him,  and  the  same  tale  was  told  at  other  places. 
His  condition  remained  much  the  same  till  eighteen 
years  of  age,  when  it  was  noticed  that  he  was  getting 
more  lazy  and  otherwise  deteriorating. 

The  following  are  examples  of  cases  presented  for 
'  Special  Instruction  "  from  Council  Schools; 


SPECIAL  INSTRUCTION  49 


NOTES  ON  ADMISSION. 

Ci:sE  IV.  (Microcephalic  type). — F.  D.,  aged  seven 
years  seven  months.  Small  for  age,  fairly  nourished, 
well  limbed.  Senses  perfect.  Head  small  with  narrow 
forehead,  tapers  towards  vertex,  circumference  19  inches. 
Palate  high  and  narrow.  Epicanthus.  Mouth  breather. 
Hands  well  extended.  Has  attended  infant  school  three 
years.  Knows  letters,  and  can  form  O,  A,  I,  T.  Cannot 
count  correctly,  and  says  that  he  has  three  eyes,  a  dog 
six  legs,  etc.  Requires  special  instruction,  but  should 
have  more  manual  than  mental  work,  as  he  seems 
subject  to  headaches.  Should  be  examined  for 
adenoids. 

CASE  V.  (Syphilitic  taint). — M.  O.,  aged  twelve. 
A  dull-looking  girl  with  dusky  complexion.  Head 
21  inches.  Radiating  lines  around  mouth.  Teeth 
"  Pe§gy«"  Sight  of  right  eye  destroyed  by  interstitial 
keratitis,  some  opacity  of  left,  but  fair  vision.  Slightly 
deaf.  Seems  to  have  been  almost  stationary  the  last 
two  years.  Is  excitable  at  times,  but  generally  slow 
in  reaction .  Reads  from  primer  in  drawling  way.  Writes 
untidily.  Can  add  and  subtract  a  little.  Unfit  for 
ordinary  standards,  but  may  learn  some  manual  work 
in  special  instruction  class,  but  will  probably  retrograde. 

CASE  VI.  (Mongolian  type). — S.  B.,  a  delicate  boy  of 
ten,  with  a  stoop.  He  cannot  quite  dress  himself,  and 
is  very  restless;  little  power  of  concentration.  He  can 
count  to  20,  but  does  not  know  what  twice  3  is. 
He  can  interpret  simple  pictures,  and  recognises  a  penny 
and  a  halfpenny,  but  said  a  sixpence  was  a  shilling. 
Unfit  for  an  ordinary  school,  but  will  improve  in  a  special 
class,  especially  when  doing  manual  work,  which  will 
provide  an  outlet  for  his  restlessness  and  strengthen  his 
power  of  concentration. 

The  following  have  been  under  special  instruction 

for  a  time: 


50        MENTALLY  DEFICIENT  CHILDREN 


CASE  VII.  (Mongoloid  type). — P.  W.,  a  fairly  grown 
girl  of  twelve,  with  obliquely-set  eyes,  rough  and  ruddy 
skin,  tongue  with  shallow  transverse  fissures,  broad, 
short-fingered  hand,  and  incurved  little  fingers.  After 
three  years'  special  instruction  has  learned  to  read  in 
second-standard  book,  to  work  addition  and  subtraction 
sums,  and  to  write  from  dictation.  She  is  also  progressing 
at  laundry  and  cookery  classes.  When  admitted  at  age 
of  nine,  incapable  of  standard  work  in  girls'  school ; 
now  fit  to  join  second  standard. 

CASE  VIII.  (Sporadic  cretin). — A.  S.,  aged  fourteen, 
admitted  four  years  ago  to  special  school,  being  unfit  for 
ordinary  school  in  consequence  of  physical  and  mental 
abnormalities  characteristic  of  cretinism.  During  the 
last  three  yea#s  has  had  thyroid  treatment  at  Children's 
Hospital,  and  has  notably  improved.  From  being  an 
inert  dwarf,  with  baggy  cheeks  and  protuberant  abdomen, 
he  has  become  an  active  (somewhat  mischievous)  boy 
of  bright  expression  and  slender  figure,  and  has  grown 
8  inches  (from  39^  to  47^)  in  last  two  years.  Now  knows 
the  letters  and  figures;  can  write  his  name  and  add  a 
little,  although  originally  absolutely  incapable  of  any 
educational  attainment. 


CHAPTER  IV 

PATHOLOGICAL  CLASSIFICATION   OF  FORMS  OF 
MENTAL  DEFICIENCY 

As  stated  in  the  preface  to  the  first  edition,  it  is 
not  intended  in  the  present  work  to  do  more  than 
glance  at  the  pathological  aspects  of  the  subject. 
Those  interested  in  these  aspects  will  find  much  that 
is  valuable  in  the  well-known  textbook  by  Ireland,* 
in  successive  volumes  of  "  Recherches  "  by  Bourne- 
ville,f  in  an  article  by  Fletcher  Beach  in  Hack 
Tuke's  |  "  Dictionary  of  Psychological  Medicine,"  in 
the  publications  of  Hammarberg,§  and  particularly 
of  J.  S.  Bolton,||  and  in  the  writings  of  Tredgold^ff 
and  Sherlock.**  The  most  important  facts  in 
pathology  from  the  clinical  point  of  view  are  those 
that  are  serviceable  in  classifying  cases.  Before 
describing  these,  however,  a  short  account  of  the 
general  pathology  may  be  interesting.  And  first 

*  Mental  Affections  of  Children,  W.  W.  Ireland,  1898. 

f  Recherches  sur  I'Epilepsie,  I'Hysterie,  et  I'ldiotie,  Paris, 
1890  et  seq. 

t  See  also  article  'on  "  Idiocy  and  Imbecility  "  in  Clifford 
Allbutt's  System  of  Medicine,  vol.  viii. 

§  Hammarberg,  Studien  iiber*  Klinik  iind  Pathologic  der 
Idiotie,"  Upsala,  1895. 

||  "  Amentia  and  Dementia,"  Journal  of  Mental  Science, 
1905  and  1906.  Also  various  contributions  to  Brain  on  "The 
Brain  in  Health  and  Disease,"  London,  1914,  etc. 

D   Mental  Deficiency,  A.  F.  Tredgold  (second  edition),  1914. 

•"*  The  Feebleminded,  E.  B.  Sherlock,  1911. 


52        MENTALLY  DEFICIENT  CHILDREN 


we  remark  that  in  connection  with  mental  deficiency 
there  are  two  main  divisions  of  cerebral  abnormality : 
(a]  that  arising  from  formative  or  developmental 
defect,  and  (b)  that  resulting  from  inflammatory  or 
degenerative  processes.  These  two  classes  are  now 
usually  spoken  of  as  Primary  and  Secondary  Amentia, 
terms  suggested  by  Dr.  Tredgold,  who  states  that  prob- 
ably about  90  per  cent,  of  all  cases  may  be  assigned 
to  the  first  group.  Primary  Amentia  denotes  mental 
defect  due  to  an  intrinsic  cause  (morbid  heredity), 
Secondary  Amentia  that  due  to  an  extrinsic  cause 
(traumatism,  disease  or  other  unfavourable  environ- 
ment). It  is  important  to  realise  that  the  second 
group  includes  a  mixed  class  of  cases,  in  which  the 
actual  lesion  supervenes  upon  a  brain  originally 
imperfect  in  development;  to  such  cases,  occurring 
at  a  crisis  of  early  life,  the  name  DEVELOPMENTAL 
is  often  applied.  The  extent  of  the  cerebral  abnor- 
mality, whether  original  or  acquired,  may  a  priori 
be  expected  to  bear  some  proportion  to  the  degree  of 
mental  defect;  this  is  usually  the  case,  though  it  is 
necessary  to  bear  in  mind  that  microscopic  as  well  as 
macroscopic  constitution  of  brain  tissue  must  be  taken 
into  account,  and  that  certain  portions  of  the  brain 
are  of  more  importance  (qua  intelligence)  than  others. 
Recent  microscopical  investigations  have  yielded 
a  rich  harvest  of  facts.  In  primary  amentia  cellular 
changes  have  been  found  in  all  regions  of  the  brain. 
The  prefrontal  and,  to  a  less  extent,  the  parietal 
lobes,  are,  however,  the  two  situations  in  which  they 
most  frequently  occur.*  Dr.  Bolton  states  that 
' '  the  regions  of  under-development  in  cases  of  mental 
deficiency  and  of  wasting  in  cases  of  dementia  (or 

*  See  also  Goulstonian  Lectures,  R.C.P.,  by  J.  S.  Bolton, 
February  and  March,  1910. 


PATHOLOGICAL  CLASSIFICATION          53 


permanent  psychic  disability  due  to  neuronic  degen- 
eration) were  satisfactorily  determined  to  have  their 
chief  focus  in  the  pref rental  region."  According 
to  Dr.  Tredgold,  "  As  compared  with  the  nerve  cells 
of  the  healthy  brain,  those  of  the  ament  are  char- 
acterised by  the  following  conditions:  (i)  Numerical 
deficiency;  (2)  irregular  arrangement;  (3)  imperfect 
development  of  individual  cells/'*  He  further  states 
"  that  the  amount  of  change  discoverable  by  the 
microscope  is  distinctly  proportionate  to  the  degree 
of  mental  deficiency  present  during  life."  Among 
other  changes  a  paucity  of  dendrons  and  gemmules 
and  pigmentation  are  noticeable.  The  pyramidal 
layer  of  the  cortex  shows  the  most  obvious  abnor- 
malities; it  is  in  its  deeper  layer  that  pigmentation 
is  most  frequently  observed.  At  the  same  time 
"  the  bands  of  tangentially  coursing  fibres  comprising 
the  association  systems  show  a  very  definite  diminu- 
tion in  cases  of  severe  amentia,  so  great,  indeed, 
as  often  to  be  apparent  to  the  naked  eye.  Generally 
speaking,  the  most  marked  alteration  occurs  in  the 
fibres  composing  the  outer  line  of  Baillarger,  next 
in  the  super-  and  inter-radial  bundles,  whilst  the 
superficial  tangential  fibres  are  somewhat  less 
affected. ' '  f  There  is  often  also  sclerosis,  or  overgrowth 
of  neuroglia,  usually  in  the  form  of  localised  patches. 
These  are  found  chiefly  in  three  situations:  (i)  the 
grey  matter  of  the  cerebral  cortex;  (2)  the  floor 
of  the  lateral  ventricles;  (3)  the  surface  of  the  hemi- 
sphere under  the  pia,  closely  applied  to  the  cortex. 
These  histological  changes  are  the  essentials  in 
mental  defect,  rather  than  the  gross  lesions  we  shall 
presently  describe. 

*  A.  F.  Tredgold,  Mental  Deficiency,  1914,  p.  75. 
f  Ibid.,  p.  79. 


54        MENTALLY  DEFICIENT  CHILDREN 


Localised  signs  of  disease  in  an  otherwise  well- 
developed  brain  are  suggestive  of  secondary  amentia 
as  distinguished  from  primary.  In  the  absence 
of  a  reliable  history,  however,  the  distinction  is 
difficult,  and  often  impossible,  especially  as  the 
dementia  that  frequently  supervenes  is  characterised 
by  histological  signs  that  obscure  the  issue. 

As  regards  macroscopic  appearances,  we  find 
that  frequently,  and  especially  in  the  more  extreme 
cases  of  mental  defect,  there  are  definite  changes 
visible  to  the  naked  eye.  The  skull  in  primary 
amentia  is  often  thick  and  dense,  and  the  diploe 
frequently  non-existent.  The  sutures  are  sometimes 
prematurely  united,  a  condition,  however,  in  no  way 
the  cause  of  poor  cerebral  development,  as  was  at 
one  time  thought. 

As  a  rule,  in  primary  amentia  the  brain  weighs  less 
than  the  normal.  It  may  be  peculiar  in  configuration, 
and  the  convolutions  may  be  irregular  or  unusually 
simply  arranged.  There  may  be  gross  malforma- 
tions of  development  connected  with  the  fissures, 
basal  ganglia,  and  other  parts. 

Defects  of  the  Corpus  Callosum  and  partial  atrophies 
affecting  portions  only  of  the  brain  are  occasionally 
seen.  Such  gross  lesions,  however,  although  more 
common  in  the  mentally  defective  and  epileptic, 
have  been  found  in  individuals  who  appeared  to  be 
normal.  They  do  not,  therefore,  predicate  mental 
defect  unless  associated  with  the  histological  changes 
already  described,  or  involving  an  area  essential  to 
the  normal  intellectual  or  psychic  processes.  Among 
some  remarkable  abnormalities  the  following  are 
specially  interesting.  In  the  autopsy  of  a  hemiplegic 
imbecile,  who  died  at  twenty-one  years  of  age,  a  gap 
4  inches  in  length  was  found  extending  from  the 


f>  ' 


PLATE  II. 


I. — PORENCEPHALUS. 

(R.A.A.  1884.) 


FIG.  2.  FIG.  3 

DEFECT  OF  CEREBELLUM. 

(R.A.A.  1884.) 
ABNORMALITIES  IN  BRAIN  STRUCTURE. 


PATHOLOGICAL  CLASSIFICATION          55 


anterior  part  of  the  right  frontal  lobe  nearly  to  the 
occipital,  leaving  the  orbital  plate  uncovered,  and 
disclosing  part  of  the  cavity  of  the  lateral  sinus 
(see  Plate  II.,  Fig.  i).  Internally,  a  narrow  ridge, 
marked  by  convolutions,  separated  this  gap  from 
the  longitudinal  sinus;  between  it  and  the  temporo- 
sphenoidal  lobe  was  seen  standing  out,  quite  un- 
covered by  convolutions,  part  of  the  caudate  nucleus. 
The  brain  weighed  32  J  ounces.  This  defect  was  due 
to  an  arrest  of  development,  as  there  was  no  cica- 
tricial  tissue  to  be  made  out,  and  no  descending 
sclerosis  of  the  spinal  cord.  The  mother  gave  an 
account  of  fright  and  injury  in  consequence  of  being 
knocked  down  by  a  cow  during  the  sixth  month  of 
pregnancy.  The  patient's  left  arm  and  hand  were 
smaller  than  the  right;  his  speech  was  indistinct, 
but  he  was  able  to  frame  ordinary  sentences ;  while  his 
senses  were  normal.  He  made  himself  useful,  and 
could  clean  shoes  well. 

A  rare  case  of  atrophy  of  the  cerebellum  was  dis- 
covered at  the  autopsy  of  an  imbecile  girl  of  fifteen, 
who  died  at  the  Royal  Albert  Asylum  of  phthisis. 
As  no  marked  ataxia  or  inco-ordination  had  been 
noticed  during  life,  it  was  with  some  surprise  that 
a  merely  rudimentary  condition  of  the  left  lobe  of 
the  cerebellum  was  observed  (see  Plate  II.,  Figs. 
2  and  3).  This  was  represented  by  a  papilla  no 
larger  than  the  nail  of  one's  little  finger,  while  the 
vermiform  process  was  a  minute  nodule  showing 
faint  signs  of  lamination  on  the  surface;  the  right 
lobe,  which  constituted  the  main  portion  of  the  cere- 
bellum,  was  only  half  a  square  inch  in  superficial 
area,  and  only  a  quarter  of  an  inch  thick  at  its  base. 
This  lilliputian  lobule  had,  however,  the  normal 
laminated  appearance  and  structure,  The  pons  was 


5 6        MENTALLY  DEFICIENT  CHILDREN 


indicated  by  a  few  transverse  fibres.  With  the  ex- 
ception of  the  cerebellum  and  its  peduncles,  the 
rest  of  the  encephalon  (which  weighed  42  ounces) 
and  the  cranial  nerves  appeared  to  be  normal.  In 
this  case  there  had  been  considerable  feebleness 
of  body  as  well  as  of  mind,  the  girl  having  suf- 
fered from  a  protracted  illness  (phthisis),  but  the 
gait  \\as  by  no  means  characteristic  of  cerebellar 
abnormality. 

We  may  appropriately  refer  here  to  the  two  inter- 
esting groups  of  cases  spoken  of  as  word-deaf  and 
word-blind,  which  are  due  to  absence  or  imperfect 
development  of  special  portions  of  the  brain.  These 
conditions  are  not  uncommon,  occurring,  according 
to  Dr.  C.  J.  Thomas,*  about  once  in  every  2,000 
children,  and  probably  at  least  once  in  every  twenty 
mentally  defective  children.  In  our  experience 
word-deafness  is  a  very  rare  condition,  while  slight 
degrees  of  word-blindness  are  not  infrequent,  even 
amongst  ordinary  school  -  children.  Just  as  with 
the  condition  of  oxycephaly  to  be  presently  described, 
the  first  accounts  were  written  by  ophthalmic  sur- 
geons, and  to  Dr.  Hinshelwoodf  in  particular  we  are 
indebted  for  some  instructive  clinical  cases.  Dr. 
Kerr,J  late  medical  officer  to  the  London  County 
Council  Education  Committee,  and  others  have  since 
described  the  condition.  Those  who  are  specially 
interested  will  find  his  papers,  and  also  those  of  Dr. 
Thomas,  §  well  worthy  of  study. 

*  Some  Forms  of  Congenital  Aphasia  in  their  Educational 
Aspects,  1905. 

f  Lancet,  May  26,  1900;  Ophthalmic  Review,  1902. 

t  Lancet,  1900,  i.,  p.  1446;  Report  of  Medical  Officer  of 
School  Board  for  London,  1904. 

§  C.  J.  Thomas,  op.  cit.,  The  Aphasias  of  Childhood  and 
Educational  Hygiene,  London,  1908. 


PATHOLOGICAL  CLASSIFICATION          57 


A  typical  WORD-DEAF  child,  though  he  does  not 
appear  to  be  as  intelligent  as  one  whose  only  defect 
is  word-blindness,  is  superior  to  the  ordinary  mental 
defective.  He  may  be  able  to  write  from  a  copy, 
to  draw  well,  and  use  his  fingers ;  his  vision  is  normal, 
and  he  is  not  really  deaf,  for  he  can  respond  by  raising 
his  head  to  sounds  of  all  kinds,  even  when  faint.  It 
is  not  the  actual  hearing  centre  which  is  at  fault,  but 
the  centre  which  interprets  the  sound  of  words  heard. 
He  can  reproduce  many  words  without  understanding 
them,  though  the  meaning  of  an  occasional  word 
may  dawn  upon  him  when  his  lips  move  to  pronounce 
it.  Some  of  these  children  keep  their  eyes  on  a 
speaker's  lips,  and  recognise  a  few  nouns  by  lip- 
reading.  The  only  chance  of  training  is  to  teach 
them  to  understand  language  by  lip-reading,  and  so 
"  connote  the  mechanism  employed  in  uttering  words 
with  their  meaning."*  This  must  be  done  at  what- 
ever cost  of  time  and  patience,  because  the  under- 
standing of  language  is  a  necessity  for  all  human 
beings. 

The  typical  WORD- BLIND  child  is  apparently  intelli- 
gent, often  clever  at  hand-work  and  drawing,  with 
good  powers  of  observation  and  reasoning;  in  calcu- 
lation and  manipulation  of  Arabic  numerals  he  may 
be  equal  to  the  normal.  He  is,  however,  quite 
unable  to  read  even  words  of  one  syllable,  and  the 
most  painstaking  attempts  to  teach  him  reading  are 
an  absolute  failure.  Vision  is  normal.  Although  he 
cannot  recognise  words,  yet  if  a  word  is  spelt  out  to 
him  he  is  often  able  to  respond  with  the  correct  one. 
Occasionally  he  is  able  to  arrive  at  the  meanings  of 

*  Dr.  Leonard  Guthrie,  "  Functional  Diseases  of  the 
Nervous  System,"  Diseases  of  Children,  edited  by  Garrod  > 
Batten,  and  Thursfield,  p.  691. 


58        MENTALLY  DEFICIENT  CHILDREN 


words  by  spelling  them  aloud.  It  is  not  the  actual 
centre  for  vision  which  is  to  blame,  but,  according  to 
Dr.  Thomas,  the  defect  is  due  to  "a  congenital 
poverty  of  structural  elements  "  of  the  visual  word- 
centre,  which  is  situated  in  the  supramarginal  and 
angular  gyri  of  the  left  side,  which  results  in  word- 
blindness. 

In  the  case  of  word-blind  children  the  auditory 
centre  can  be  trained  to  supplement  the  visual,  and 
also  much  may  be  done  to  develop  a  kinsesthetic 
memory  of  word-meanings  by  making  the  pupil  move 
his  lips  as  he  reads,  or  trace  the  words  on  paper,  or 
by  the  use  of  the  Braille  raised  type.  The  process 
is,  however,  so  laborious  and  slow,  and  the  ultimate 
result  so  far  from  being  really  satisfactory,  that  with 
working-class  children,  at  any  rate,  time  should  not 
be  wasted  in  any  attempts  of  the  kind,  but  the  child 
should  be  put  at  once  to  tasks  for  which  he  has  more 
natural  capacity. 

The  condition  designated  Mind-Blindness  is  one 
essentially  of  the  receiving  rather  than  the  storing 
visual  centre ;  for  this  "  a  lesion  of  the  posterior  part 
of  the  corpus  callosum  is  generally  considered,  at  least 
partly,  responsible . "  * 

We  have  often  thought  that  a  similar  explanation 
may  be  given  for  some  at  least  of  the  cases  spoken 
of  as  MORAL  DEFECTIVES,  an  account  of  which  we 
have  included  in  the  next  chapter.  Moral  sense 
must  depend  on*  the  integrity  of  more  than  a  single 
area  of  the  brain ;  a  lesion  of  one  of  the  areas  involved, 
or  of  some  of  the  connecting  fibres,  can  scarcely  fail 
to  have  serious  consequences. 

*  Brain,  Vol.  36,  p.  119,  "Experimental  and  Patho- 
logico-Anatomical  Researches  on  the  Corpus  Callosum/'  by 
Dr.  C.  T.  Van  Valkenburg,  Amsterdam. 


PLATE  III. 


FlG.    I. MlCROCEPHALIC    BRAIN    (CONVEXITY). 

(Half  natural  size.) 


A 


-D 


FIG.  2. — BRAIN  OF  "FREDDY"  (CONVEXITY). 
(Natural  size,  after  preservation  in  spirit.) 

MlCROCEPHALIC  BRAINS. 


PATHOLOGICAL  CLASSIFICATION          59 


Of  the  obvious  primary  abnormalities,  no  condition 
is  more  striking  than  that  of  Microcephalus.  Charac- 
teristic in  its  extreme  form  of  a  low  type  of  idiocy, 
in  which  have  been  traced  simian  and  even  theroid 
resemblances,  it  may  be  'traced  through  a  series  of 
gradations  of  head  measurement  from  idiocy  and 
imbecility  to  simple  "  feeble-mindedness."  Micro- 
cephalus, however,  does  not  depend  solely  upon 
diminutive  size  of  the  head,  as  ascertained  by 
measurement.  In  our  opinion  the  limitation  of  the 
term  proposed  by  some  *  to  cases  in  which  the  cranial 
circumference  does  not  exceed  17  inches  is  scarcely 
scientific.  There  is  a  characteristic  form,f  as  well 
as  size,  indicative  of  microcephaly,  consisting  of  a 
narrow,  rapidly  receding  forehead,  a  somewhat 
pointed  vertex,  and  a  flat  occiput.  The  frontal  and 
parietal  lobes  are  on  a  small  scale,  but  it  is  in  the 
occipital  and  temporo-sphenoidal  that  we  usually 
find  the  most  striking  evidence  of  arrest  in  develop- 
ment. This  is  well  shown  in  the  case  of  a  micro- 
cephalic  girl  of  fifteen,  formerly  under  the  care  of 
Dr.  Shuttleworth,  at  the  Royal  Albert  Asylum,  whose 
brain  was  fully  described  by  him  in  the  Journal  of 
Mental  Science  for  October,  1878.  A  view  of  the  con- 
vexity of  the  brain,  which  weighed,  when  removed, 
only  2i|  oz.,  is  appended  (Plate  III.,  Fig.  i,  half 
size.)J  A  still  more  remarkable  case  ("Freddy"), 
for  twenty  years  under  Dr.  Shuttleworth's  observa- 

*  Ireland,  op.  cit.,  p.  89. 

f  See  Plate  IV.,  Fig.  i,  p.  60. 

J  DESCRIPTION  OF  PLATE  III. — FIG.  i. — General  view  of 
Microcephalic  Brain  seen  from  above.  A.  Parieto-occipital 
fissure.  B.  Horizontal  fissure.  C.  Ascending  limb  of  Sylvian 
fissure.  D.  Fissure  of  Rolando. 

FIG.  2. — Lettering  as  in  Fig.  i.  See  also  Trans.  Roy 
Dublin  Society,  new  ser.,  vol.  v.,  plate  xxxvi. 


MENTALLY  DEFICIENT  CHILDREN 


tion  at  Lancaster,  was  anatomically  reviewed  by  Dr. 
Telford  Smith  and  the  late  Professor  Cunningham.* 
His  brain,  when  recent,  weighed  only  12^  ounces. 
The  convolutions  were  simple;  fairly  distinguishable 
in  the  anterior  lobes,  they  became  rudimentary 
posteriorly,  the  occipital  and  temporo-sphenoidal 
lobes  being,  indeed,  very  imperfectly  developed. 
This  "  Aztec  "-like  youth, J\  who  had  large  bright 
eyes,  an  aquiline  nose,  and  somewhat  receding 
chin,  manifested  good  powers  of  observation,  but 
was  only  able  to  make  use  of  a  few  monosyllabic 
words  He  had  considerable  will  power,  and  was 
in  no  sense  a  low-grade  idiot,  though  but  little 
amenable  to  training.  We  have  repeatedly  seen 
boys  and  girls  with  heads  measuring  only  19  inches 
taught  to  read  and  write,  and  do  industrial  work. 
Quality  of  brain  is  an  important  factor,  as  well 
as  quantity;  in  cases  of  microcephalus  what  little 
there  is,  is  usually  fairly  active.  The  condition  of 
infantilism,  which  is  described  in  the  next  chapter  in 
connection  with  cretinism,  is  sometimes,  however, 
a  prominent  factor.  Many  microcephalies  are 
dwarfs. 

Primary  cases  of  Hydroeephalus  are  not  infrequent, 
though  the  condition  is  also  secondary.  In  both 
conditions  the  hydrocephalus  may  be  either  internal 
or  external,  the  latter  being  much  the  rarer  form. 
Very  different  degrees  of  mental  enfeeblement  are 
met  with  in  this  type,  and  it  is  remarkable  that  a 
considerable  amount  of  intelligence  may  subsist  with 
a  very  watery  brain,  as  in  the  case  of  a  girl  of  eleven, 
peculiar,  but  only  slightly  imbecile,  who  continued 
to  converse  rationally  till  within  an  hour  of  her  death, 

*  Trans.  Roy.  Dublin  Society,  vol.  v.,  ser.  2,  part  viii. 
f  See  Plate  IV.,  Fig.  i,  and  Plate  III.,  Fig.  2,  p.  59. 


PLATE  IV. 


FIG.  i. — "FREDDY"  (ROYAL 
ALBERT  ASYLUM). 


FIG.  2  (SPECIAL  SCHOOL). 


FIG.  3  (SPECIAL  SCHOOL). 
MICROCEPHALIC  CASES. 


w 

H 


PH 


6 

H 

O 

— 

i-J 


w 
o 
o 

P4 
Q 
>H 

tu 


PATHOLOGICAL  CLASSIFICATION          61 


when  it  was  found  that  her  large  globular  skull* 
contained  20  ounces  of  fluid  to  36  of  cerebral  matter. 
In  some  cases  optic  neuritis  and  signs  of  pressure 
occur,  and  convulsions  usher  in  a  fatal  termination. 
As  a  rule,  indeed,  it  is  only  in  cases  where  active 
symptoms  have  subsided  that  educational  methods 
are  admissible.  Plate  V.,  Fig.  2,  portrays  a  hydro- 
cephalic  youth,  with  a  head  circumference  of  23  inches, 
in  whose  case  the  chief  residual  indication  of  defect 
was  in  the  direction  of  moral  imbecility.  In  some 
cases  syphilitic  or  tubercular  lesions  have  been  found ; 
these  would  suggest  that  the  case  belongs  to  the 
secondary  class,  as  does  also  the  finding  of  a  positive 
Wassermann  reaction. 

In  Hypertrophie  cases  the  head  is  also  enlarged, 
though  not  to  the  same  extent  as  in  hydrocephalus, 
no  record,  existing  of  one  over  25  inches;  nor  is  the 
enlargement  in  the  same  directions,  the  shape  being 
square  rather  than  round.  There  is  no  excess  of 
fluid,  but  an  enlargement  of  the  brain  substance; 
the  hypertrophy,  however,  affects  the  interstitial 
tissue  only,  and  is  a  diffuse  gliosis.  The  distinction 
between  these  cases  and  hydrocephalus  is  not  diffi- 
cult, as  will  be  shown  in  the  next  chapter. 

A  frequent  congenital  type,  obtaining  (in  England, 
at  least)!  in  nearly  5  per  cent,  of  mentally  defective 
children,  in  greater  or  less  degree,  is  that  which  has 
been  designated  "  Mongol "  or  "  Kalmue,"  owing  to 
the  physiognomical  resemblance  to  those  races.  In 
these  cases  the  skull  is  a  short  oval,J  the  transverse 
and  longitudinal  diameters  approximating,  while 

*  See  Plate  XII.,  Fig.  3,  p.  105. 

f  See  paper  on  "  Mongolian  Imbecility/'  by  G.  E.  Shuttle- 
worth,  British  Medical  Journal,  September  n,  1909. 

t  See  Plate  XII.,  Fig.  2,  p.  105;  Plate  XIV.,  Fig.  i,  p.  119. 


62        MEN  TALLY  DEFICIENT  CHILDREN 

there  is  a  tendency  to  parallelism  of  the  frontal  and 
occipital  planes.  In  children  of  this  type  the  brain 
is  not  necessarily  small,  but,  according  to  Dr.  A.  W. 
Wilmarth,*  whose  observations  are  confirmed  by 
Dr.  Tredgold,  there  is  a  notable  diminution  in  the  size 
of  the  pons,  medulla,  and  cerebellum.  It  has  been 
suggested  that  the  imperfect  development  of  these 
parts  may  result  in  a  deficient  expansion  of  the  base 
of  the  skull,  and  that  this  leads  to  the  characteristic 
physiognomy.  The  brain  is  characterised  by  great 
simplicity  of  development,  and  by  paucity  of  multi- 
polar  cells.  The  convolutions  are  large  and  coarse, 
and  there  are  few  secondary  convolutions,  f  Babon- 
neix,J  Fromm,§  Bernheim-Karrer,||  Lange,^  and 
others,  have  found  abnormalities,  such  as  hypo- 
plasia,  sclerosis,  atrophy,  and  haemorrhages,  in  the 
thyroid  gland  in  some  cases  of  Mongolism.  So  many 
other  cases  have,  however,  been  examined  and  found 
to  possess  a  normal  thyroid  that  we  are  justified  in 
assuming  that  when  a  lesion  of  the  thyroid  does  occur 
it  is  an  accidental  complication,  and  not  necessarily 
associated. 

The  characteristic  features  of  the  Mongolian  type 
will  be  further  discussed  in  the  next  chapter,  which 
treats  of  diagnosis. 

There  is  a  large  group  of  cases  in  which  mental 

*  A.  W.  Wilmarth,  "  Report  on  the  Examination  of  One 
Hundred  Brains  of  Feeble-Minded  Children,"  Alienist  and 
Neurologist,  October,  1890. 

f  See  Plate  VI.,  Figs,  i,  2,  and  3. 

{  Babonneix,  "  Contribution  a  l']±tude  anatomique  de 
I'ldiotie  Mongolienne,"  Archives  de  Medecine  des  Enfants, 
July,  1909. 

§  Fromm,  Jahrb.  fur  Kinderheilk.,  November,  1905. 

||  Bernheim-Karrer,  Jahrb.  fur  Kinderheilk.,  1906,  p.  26, 
'If  Lange,  Jahrb.  fiir  Kinderheilk.,  1906,  p.  753. 


PLATE,  -VI,  •••.'.*• 


FIG.  i. 
(CONVEXITY.) 


FIG.  3. 
(LEFT  LATERAL  VIEW.) 

"MONGOL"  BRAIN. 


PLATE  VII. 


FIG.  i. — AMERICAN  IMBECILE  WITH  "  LEPTOCEPHALIC  "  CRANIUM. 


FIG.  2. — AMERICAN  HIGH-GRADE  IMBECILE  WITH  SCAPHOCEPHALIC 

CRANIUM. 

(J.  Moorhead  Murdoch,  M.D.) 
From  Journal  of  Psycho- Asthenias,  vol.  xi.  (by  kind  permission). 

To  face  page  63. 


PA TUOLOG1CAL  CLA SStfitCA TtON      _j* 

deficiency  dating  from  birth  may  be  said  to  depend 
upon  a  highly  neurotic  heredity.     It  is  probable 
in  such  cases  there  is  original  defect  in  constitution 
of  neurones  with  a  tendency  to  irregular  discharge, 
and  an  imperfection  of  those  inhibitory  arrangements 
which  are  gradually  evolved  in  the  normal  child. 
Dr  J.  Langdon-Down  long  ago  pointed  out 
quent  association  with  the  neurotic  type  of  a     prow- 
shaped  skull  "-i.e.,  a  cranium  tapering  anteriorly 
to  a  prominent  ridge  marking  the  position  of  the 
medio-frontal  suture,  synostosis  of  which  has  bee, 
deferred,  owing  to  some  intra-uterine  check,  which 
has  also  arrested  the  development  of  the  cerebral 
centres,  and  rendered  them  unstable.     Such  cases 
have  been  designated  Scaphocephalic,\  and  even  i 
they  show  no  marked  intellectual  defect  in  early 
childhood,  are  apt  to  break  down  from  the  strain  o 
second  dentition  or  of  puberty. 

Cases  which  do  not  conform  to  any  of  the  above 
types,  but  still  show  abnormal  configuration,  are 
spoken  of  by  some  authorities  as  Simple  Congenital. 
This  group  has  been  well  described  by  Dr.  Fletcher 
Beach  i  They  show  no  marked  deformity  of 
skull  or  limbs,  but  are  usually  below  the  average 
height.  The  expression  of  the  face  is  vacant, 
are  several  obvious  anatomical  peculiarities,  the 
so-called  stigmata  of  degeneration.  These  are  usually 
multiple,  instead  of  occurring  singly,  as  may  happen 
in  normal  individuals.  Found  in  the  face,  head,  and 
hand,  they  take  the  form  of  obliteration  or  exaggera- 

*  Mental  Affections  of  Childhood  and.  Youth,  J,  Langdon- 
Down,  1887. 

t  See  Plate  VII.,  Fig-  2. 

•<•  Types  of  Mental  Deficiency,   Report  of  tirst  National 
Conference  of  Special  School  Teachers,  held  in  Manches 
(Tinling  and  Co.,  Liverpool),  1904- 


64        MENTALLY  DEFICIENT  CHILDREN 


tion  of  normal  markings,  such  as  those  of  the  anti- 
helix  or  other  parts  of  the  ear,  or  consist  in  marked 
diminution  in  size  of  the  mouth,  orbital  fissures,  or 
lower  jaw.  The  teeth  are  often  irregular,  and  may 
be  arranged  in  two  rows,  while  the  ear  may  be  im- 
planted too  far  back.  At  the  present  time,  however, 
the  custom  of  most  authorities  is  to  classify  together 
under  the  term  Simple  Primary  Amentia  both  this 
group  and  the  larger  one,  which  shows  no  abnormal 
configuration  at  all.  Although  there  is  no  external 
abnormality,  the  brain,  when  examined,  usually  shows 
some  of  the  pathological  conditions  we  described  in 
the  first  instance.  This  class,  although  placed  last 
on  our  list,  includes  much  the  greater  proportion  of  all 
cases  of  primary  mental  defect. 

Both  Epilepsy  and  Paralysis  may  occur  as  a  com- 
plication of  primary  amentia.  These  cases  must  be 
distinguished  from  cases  of  secondary  amentia,  which 
are  due  to  epilepsy,  or  to  traumatism  or  disease 
occurring  at  or  after  birth,  and  affecting  both  the 
motor  and  intellectual  areas  of  the  brain. 

We  have  now  traced  the  prominent  pathological 
conditions  of  the  several  typical  varieties  of  primary 
mental  deficiency — viz. : 

1 .  Defects  of  Special  Areas  and  Partial  Atrophies 
(including  Word-deafness  and  Word-blindness). 

2.  Microcephalus. 

3.  Hydrocephalus  (primary). 

4.  Hypertrophie. 

5.  "  Mongol  "  or  "  Kalmuc  "  typj. 

6.  Primarily  neurotic  (including  Seaphoeephaly), 

7.  Simple  Primary  Amentia. 

In  the  intermediate  group  of  cases,  which  we  have 
referred  to  as  DEVELOPMENTAL,  we  include  those 


PATHOLOGICAL  CLASSIFICATION          65 


forms  of  mental  weakness  which  evidence  them- 
selves at  some  crisis  of  development,  such  as  the 
first  or  second  dentition,  or  the  epoch  of  puberty, 
but  are  traceable  to  an  original  defect  of  nervous 
constitution.  Epiloia  or  tuberous  sclerosis,  and  some 
eclampsic,  epileptic,  syphilitic,  and  post-febrile  cases, 
may  be  thus  classified. 

Epiloia  or  Tuberous  Sclerosis. — As  long  ago  as  1880* 
Bourneville  drew  attention  to  a  case  which,  at  the 
autopsy,  showed  tumours  in  the  kidney,  in  addition  to 
rounded  areas  of  sclerosis  in  the  brain.  Subsequently 
he  and  others  described  similar  cases,  and  in  1908 
H.  Voght  reviewed  thirty  cases,  including  three  of 
his  own.  These  were  called  "  tuberose  "  or  "  hyper- 
trophic  "  sclerosis.  Till  recently  it  was  difficult,  if 
not  impossible,  to  separate  this  group  as  a  clinical 
entity.  The  knowledge,  however,  that  sometimes 
the  cerebral  and  renal  changes  coexist  with  the 
skin  affection  known  as  "  adenoma  sebaceum  "  may 
enable  us  to  diagnose  the  condition  during  life 
Hence  the  group  designated  by  some  "  Tuberous 
Sclerosis,"  and  by  Sherlock  "Epiloia,"  which  we 
now  place  among  the  clinical  types.  Epiloia  is  a  rare 
levelopmental  disease,  characterised  by  numerous 
rounded  tumours  scattered  throughout  the  cortex 
of  the  brain;  they  may  form  projections  on  the  sur- 
face, and  also  extend  into  the  subjacent  tissue.  In 
addition  to  the  tumours  in  the  kidney,  tumours  may 
also  be  found  in  the  heart  (rhabdomyomata),  and  in 
the  breast,  thyroid,  thymus,  pancreas,  and  duo- 
denum. The  skin  tumours  (designated  by  derma- 
tologists adenoma  sebaceum)  are  seen  chiefly  on  the 
face,  round  the  nose  and  mouth,  and  on  the  fore- 
head; they  are  "  composed  of  little  red  nodules  of 

*  Archives  de  Neurologie,  1880. 


66       MENTALLY  DEFICIENT  CHILDREN 

sebaceous  gland  tissue  embedded  in  a  vascular 
matrix/'  Dr.  John  Thomson,*  to  whom  we  are 
largely  indebted  for  our  description,  says  that  the 
brain  condition  probably  dates  from  the  seventh 
month  of  fcetal  life,  or  soon  after  it. 

The  convulsions  which  generally  occur  may  begin 
in  very  early  life,  but  are  often  deferred  till  late  child- 
hood. The  child  may  show  no  sign  of  mental  defect 
till  after  the  convulsions  have  continued  for  some  time. 

Eclampsic  and  Epileptic  Cases. — A  large  number  of 
cases  of  mental  deficiency  are  attributed  by  parents 
to  convulsions  during  dentition.  Thickened  cerebral 
membranes,  sometimes  thickened  skulls,  are  seen  in 
many  of  these  cases,  with  consequent  atrophic  changes 
in  the  brain  substance.  In  cases  of  persistent  epilepsy, 
with  mental  weakness,  the  same  class  of  lesions  is 
sometimes  met  with,  though,  of  course,  the  fons  et 
origo  mali  is  to  be  looked  for  in  the  minute  structure 
of  the  nervous  tissue.  As  a  matter  of  fact,  there  is 
no  clear  distinction  between  infantile  convulsions  and 
epilepsy.  Most  infants  who  have  teething  fits  are  of 
neurotic  heredity,  and  a  number  of  them  are  the 
victims  later  on  of  "  idiopathic  "  epilepsy. 

When  epilepsy  does  exist  from  an  early  age  in 
mentally  deficient  children,  it  should  be  regarded  as 
a  complication;  it  is  a  complication  to  which  many 
defectives,  especially  lower  grade  cases,  are  liable. 
It  is  often  associated  with  hydrocephalus,  and  is  fre- 
quently noticed  in  syphilitic  cases.  In  Mongolians 
it  is  comparatively  uncommon.  Sometimes  epileptic 
seizures,  occurring  for  the  first  time  in  children,  are 
followed  by  signs  of  mental  deficiency,  although  pre- 

*  John  Thomson,  M.D.,  "  Congenital  Mental  Defect  it 
Childhood,"  Diseases  of  Children,  edited  by  Garrod,  Batten, 
and  Thursfield,  London,  1913,  p.  882. 


PATHOLOGICAL   CLASSIFICATION         67 

viously  the  child  was  known  to  be  of  normal  intelli- 
gence. These  cases  should  be  described  as  cases  of 
secondary  amentia,  due  to  epilepsy.  The  exact 
classification  of  a  particular  case  is  often  difficult. 
Idiopathic  epilepsy  cannot  as  a  rule  be  diagnosed 
till  after  the  primary  dentition  is  complete,  while  it 
is  sometimes  impossible  to  differentiate  slight  mental 
defect  from  mere  dulness  or  backwardness  till  six  or 
even  seven  years  of  age.  In  cases  of  epilepsy,  as  in 
some  other  cases  of  mental  defect,  especially  if  there 
is  any  history  of  traumatism,  a  careful  X-ray  examina- 
tion may  show  an  injury  to  the  skull  or  other  patho- 
logical condition  amenable  to  surgical  treatment.* 

It  is  important  to  examine  the  Sella  Turcica  and  its 
immediate  neighbourhood  to  see  if  there  is  any  indica- 
tion of  an  abnormal  condition  of  the  pituitary  gland. 
Epilepsy  sometimes  follows  bursting  fractures  of  the 
base  of  the  skull;  in  such  cases  the  pituitary  body 
is  liable  to  be  injured.  \  There  is,  however,  another 
class  of  patient,  according  to  Dr.  George  C.  Johnston,  J 
who,  with  an  uneventful  history,  no  injury,  and 
previous  good  health,  between  fifteen  and  twenty- 
live  years  of  age,  begin  to  suffer  from  attacks  of 
petit-mal,  gradually  increasing  in  severity  and  fre- 
quency. In  such  cases  there  are  often  changes  in 
the  Sella  lurcica — viz.,  "  for  the  most  part  an  over- 
growth of  the  anterior  and  posterior  clinoidal  pro- 
cesses, which,  in  addition  to  an  increase  in  area  and 
length,  are  slowly  folded  over  and  down  upon  the 
pituitary  gland,  enclosing  it  within  a  bony  basket. 

*  See  Plates  XIII.  and  XIIlA.,  p.  108. 

f  Harvey  Gushing,  M.D.,  The  Pituitary  Body  and  its  Dis- 
orders, p.  272.  J.  B.  Lippincott  Company. 

J  George  C.  Johnston,  M.D.,  "  The  Pituitary  Gland  in  its 
Relation  to  Epilepsy/'  Surgery,  Gynaecology,  and  Obstetrics, 
April,  1914. 


68        MENTALLY  DEFICIENT  CHILDREN 

In  addition  to  this  process,  which  evidently  is  one 
requiring  a  considerable  length  of  time  for  its  accom- 
plishment, there  is  very  often  noticeable  a  decided 
difference  in  the  size  of  the  pituitary  fossa,  and  there- 
fore of  the  gland  itself.  The  fossa  is  thus  largely  or 
completely  roofed  over  in  some  cases  in  which  the 
shadows  of  the  anterior  and  posterior  clinoidal  pro- 
cesses not  only  meet,  but  overlap.  The  frequency  with 
which  this  condition  has  been  found  is  quite  striking. 
"  In  addition  to  this  overgrowth  of  the  clinoidal 
process,  a  large  proportion  of  the  cases  show  distinct 
increase  in  density  in  the  bony  tissues  forming  the 
roof  of  the  orbit,  the  sphenoidal  sinus,  and  the  eth- 
moidal  cells.  In  quite  a  number  of  cases  the  sphe- 
noidal cells  are  decidedly  blocked  with  newly  formed 
bony  tissue.  This  condition  resembles,  to  a  marked 
degree,  the  appearance  of  the  skull  in  general  acrome- 
galy,  and  has  been  interpreted  by  us  as  a  local- 
ised acromegaly."  Dr.  Johnston  goes  on  to  say  that 
if  in  the  skiagrams  of  cases  in  this  class  the  clinoidal 
processes  do  not  show,  it  is  probably  hypopituitarism, 
due  to  hypophysial  struma  with  enlargement  of  the 
gland  and  pressure  atrophy  of  the  processes.  He 
suggests  that  we  want  an  operation  for  the  removal 
of  one  or  both  processes  in  choked  pituitary  before 
the  gland  has  suffered  too  long. 

Surgical  treatment  is  sometimes  useful  in  cases  of 
Status  Epilepticus,  which  may  be  due  to  a  localised 
'  meningitis  serosa  externa.  Dr.  Leonard  Guthrie* 
states  that  "  a  number  of  such  cases  in  which  the 
subarachnoid  cisterns  have  been  opened  and  drained, 
with  great  relief  to  the  patient,  have  recently  been 
recorded." 

*  Diseases   of   Children,  edited    by   Garrod,   Batten,    and 
Thursfield,  1913,  p.  714. 


PATHOLOGICAL  CLASSIFICATION          69 

In  connection  with  the  pathology  of  epilepsy,  refer- 
ence must  be  made  to  the  work  of  Dr.  Alfred  Gordon,* 
of  Philadelphia.  Dr.  Gordon  assumes  that  "  the 
pathogenesis  of  the  malady  presupposes  a  constant, 
or  at  least  a  frequent,  formation  in  the  organism  of 
the  epileptic  individual  of  unusually  severe  or  of 
specially  toxic  elements,  which  cause  cerebral  irrita- 
tion, manifesting  itself  in  convulsive  seizures/'  After 
referring  to  Ceni's  and  Donath's  investigations  upon 
the  chemical  constitution  of  the  blood-serum  and  the 
cerebro-spinal  fluid  in  epilepsy,  he  states  that  other 
writers  have  shown  that  there  is  a  marked  toxicity 
of  the  cerebro-spinal  fluid  in  epilepsy.  Dr.  Gordon 
himself  noticed  that  the  blood  accidentally  in  the 
cerebro-spinal  fluid  drawn  from  an  epileptic  under- 
went haemolysis;  he  also  noticed  that,  when  the 
patient  improved  and  the  seizures  became  very  mild 
and  rare,  this  phenomenon  disappeared.  He  found, 
further,  that  one  drop  of  blood  from  the  finger  of  one 
patient  in  fifteen  drops  of  cerebro-spinal  fluid  from 
another  undergoes  haemolysis,  and  vice  versa ;  but 
one  drop  of  blood  from  the  finger  of  a  patient  in  that 
patient's  own  cerebro-spinal  fluid  remains  coagulated 
for  days.  This  meant  that  the  cerebro-spinal  fluid  of 
each  patient  contained  elements  antagonistic  to  the 
other's  blood,  but  not  to  that  from  the  same  subject. 
He  therefore  withdrew  30  c.c.  of  cerebro-spinal  fluid 
from  each  of  two  epileptics,  and  injected  into  the  arm 
of  each  3  c.c.  of  the  other's  fluid.  Dr.  Gordon  treated 
four  cases  in  this  way,  and  in  all  there  was  a  great 
improvement ;  yet  all  of  them  had  had  bromide  before 
without  benefit.  The  fact  that  in  one  of  the  four 
cases  no  cerebro-spinal  fluid  was  withdrawn  proved 

*  Alfred  Gordon,  M.D.,  New  York  Medical  Journal,  1914, 
xcix.,  p.  10. 


yo        MENTALLY  DEFICIENT  CHILDREN 


that  the  improvement  could  not  be  attributed  to  the 
withdrawal  of  cerebro-spinal  fluid. 

As  will  be  fully  explained  in  the  next  chapter 
when  discussing  etiology,  although  one  investigation* 
sets  forth  that  in  nearly  50  per  cent,  of  cases  of 
epilepsy  in  children  the  Wassermann  reaction  showed 
a  syphilitic  infection,  and  that  when  the  investiga- 
tion is  extended  to  the  families  giving  a  negative 
or  doubtful  reaction  the  percentage  is  higher  still, 
we  do  not  consider  that  it  has  yet  been  proved  that 
syphilis  is  the  most  frequent  cause  of  epilepsy. 

In  regard  to  Syphilitic  cases,  our  ideas  have  been 
modified  in  recent  years  by  the  careful  investigations 
of  Dr.  Mott,  and  by  the  help  of  the  Wassermann 
reaction.  In  our  last  edition  we  suggested  that  the 
number  of  cases  of  mental  defect  due  to  syphilis  was 
larger  than  was  generally  realised.  Now,  as  will  be 
explained  in  discussing  the  etiology  in  the  next 
chapter,  we  know  that  syphilis  is  responsible  for  a 
considerable  percentage  of  cases,  many  of  which 
show  neither  the  ordinary  syphilitic  stigmata,  nor 
any  evidence  of  a  gross  lesion  in  the  central  nervous 
system.  This  is  not  surprising,  considering  that  the 
''gross  changes  in  the  brain  which  are  known  to  be 
due  to  congenital  syphilis  are  not  compatible  as  a  rule 
with  a  continuance  of  life/'f  Cases  of  mental  defect 
in  which  the  causal  relation  with  syphilis  is  deter- 
mined only  by  the  Wassermann  reaction  or  by  an 

*  Kate  Fraser,  M.B.,  and  H.  Ferguson  Watson,  M.B., 
"  The  Role  of  Syphilis  in  Mental  Deficiency  and  Epilepsy: 
a  Review  of  205  Cases,"  The  Journal  of  Mental  Science, 
October,  1913. 

|  H.  R.  Dean,  M.B.,  "  An  Examination  of  the  Blood-Serum 
of  Idiots  by  the  Wassermann  Reaction,"  Proceedings  of  the 
Royal  Society  of  Medicine,  Neurological  Section,  vol.  iii., 
June,  1910,  p.  117. 


PLATE  VIII. 


INHERITED  SYPHILIS. 


To  face  page  70. 


PATHOLOGICAL  CLASSIFICATION          71 


investigation  of  other  members  of  the  family  may  be 
classed  as  parasyphilitic. 

It  is  important  to  remember  that  congenital 
syphilis  affecting  the  nervous  system  of  infants  and 
young  children  may  "  give  rise  to  a  meningitis,  a 
hydrocephalus,  to  an  endarteritis,  to  gummata,  to 
a  juvenile  tabes,  and  to  a  juvenile  general  paralysis  of 
the  insane."* 

As  regards  the  particular  type  of  mental  defect 
that  may  result  from  congenital  syphilis,  Dr.  Plaut,t 
working  in  Kraepelin's  clinique,  showed  that  in  cases 
of  imbecility  with  motor  paralysis,  syphilis  played 
an  important,  though  previously  unsuspected,  part. 
This  has  since  been  confirmed  by  Dr.  Leslie  Gordon,  J 
among  others.  The  relation  of  syphilis  to  hydro- 
cephalus is  well  known.  Apart  from  these  types, 
congenital  syphilis,  according  to  Dr.  Gordon,  "  is  as 
likely  to  cause  a  simple,  uncomplicated  form  of  con- 
genital mental  defect  as  it  is  to  cause  any  particular 
type  " — a  statement  which  is  in  accordance  with  our 
own  experience. 

There  is  one  type  of  mental  defect  universally 
admitted  to  be  due  to  syphilis  in  every  case — viz., 
Juvenile  General  Paralysis  of  the  Insane.  In  these 
cases  mental  deterioration  does  not  usually  show 
itself  until  the  period  of  the  second  dentition,  though 
Dr.  Mott§  says  the  mental  deficiency  may  date  from 
birth.  These  cases  progress  in  much  the  same  manner" 

*  F.  E.  Batten,  M.D.,  Diseases  of  Children,  edited  by 
Garrod,  Batten,  and  Thursfield,  1913,  p.  850. 

f  Plant,  Die  Wassermannsche  Serodiagnostik  der  Syphilis, 
Jena,  1909. 

{  J.  Leslie  Gordon,  M.D.,  "  The  Incidence  of  Inherited 
Syphilis  in  Congenital  Mental  Deficiency,"  Lancet,  Sep- 
tember 20,  1913. 

§  F.  W.  Mott,  M.D.,  Archives  of  Neurology,  1898,  i.  250. 


72        MENTALLY  DEFICIENT  CHILDREN 

as  general  paralysis  of  the  insane  in  the  adult,  death 
occurring  in  a  few  years  after  the  onset  of  the  symp- 
toms. A  full  description  of  these  cases  will  be  found 
in  the  next  chapter.  At  the  autopsy  we  find  thicken- 
ing of  the  cerebral  arteries  (from  endarteritis)  and 
of  the  meninges,  with  marked  atrophy  of  the  con- 
volutions; the  sulci  are  wide,  the  ventricles  dilated, 
the  ependyma  granular,  and  the  brain  wasted  as  a 
whole  (Plate  VIII.  represents  this  type).  "  On 
microscopical  examination,  the  fibres  of  the  cortex 
have  to  a  large  extent  disappeared,  and  there  is 
almost  complete  absence  of  the  tangential  fibres  of 
the  cortex.  The  cells  of  the  cortex  show  various 
stages  of  chromatolysis;  many  have  already  dis- 
appeared or  been  replaced  by  calcareous  deposits. 
The  pyramidal  tracts,  and  in  some  cases  the  pos- 
terior columns  of  the  cord,  show  degeneration/'* 

Amongst  other  pathological  conditions  sometimes 
met  with,  dating  from  early  life,  are  those  resulting 
from  meningeal  haemorrhage  occurring  from  undue 
pressure  during  parturition,  the  injurious  element 
being,  however,  prolonged  pressure  rather  than  in- 
strumental interference.  In  these  cases  atrophic 
changes  take  place  in  the  Rolandic  area,  and  as  a 
consequence  ensue  spastic  contractions  of  the  limbs 
(bilateral  or  unilateral),  with  inco-ordination  and 
often  "athetoid,"  "  choreic,"  or  "perverse"  move- 
ments. The  intellectual  deficiencies  of  children 
suffering  from  "Birth-palsies"  are  more  apparent 
than  real,  the  intelligence  which  they  possess  being 
masked  by  their  physical  infirmities,  f 
Of  clearly  SECONDARY  cases  two  main  divisions 

*  F.   E.   Batten,   M.D.,   Diseases   of  Children,    edited    by 
Garrod,  Batten,  and  Thursfield,  1913,  p.  851. 
f  See  Plate  IX.,  Figs,  i  and  2. 


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W 

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PATHOLOGICAL  CLASSIFICATION          73 

are  Traumatic  and  Post-febrile,  and  in  each  the 
characteristic  lesions  are  the  products  of  inflam- 
matory processes .  Thickened  and  adherent  mem- 
branes, following  meningeal  inflammations  and  inter- 
fering with  the  due  supply  of  blood  to  the  cerebral 
cortex,  have  been  noticed  in  a  considerable  number 
of  cases;  whilst  porencephalus,*  which  may  be  con- 
sidered in  some  instances  to  be  the  terminal  con- 
dition of  an  acute  inflammatory  lesion,  has  not  in- 
frequently been  observed.  It  must  be  noted,  how- 
ever, that  some  of  the  cases  in  which  sclerosis  is 
found  are  not  strictly  secondary,  as  was  at  one  time 
supposed,  but  belong  to  the  "  Tuberous  Sclerosis  " 
group,  a  developmental  type. 

Among  the  cases  probably  due  to  meningitis  is  a 
peculiar  form  of  enlargement,  in  one  direction  at 
least,  of  the  skull,  known  as  Oxycephaly,  or  Tower 
skull  (French,  Tete  a  tour ;  German,  ThurmscMdel). 
This  type  is  not  frequently  met  with,  and  has  seldom 
been  described  from  the  mental  aspect.  It  has 
sometimes  been  confused  with  other  types.  For 
most  of  the  descriptions  we  are  indebted  to  ophthal- 
mic surgeons,  as  the  ocular  defects,  which  are  usually 
the  most  marked,  have  attracted  more  attention 
than  the  mental.  Indeed,  Patry  states  that  the  in- 
telligence is  usually  normal.  In  some  cases,  how- 
ever, there  has  been  marked  mental  defect.  It  is 
probable  that  slight  mental  defect  would  be  found 
in  most  cases  if  the  investigations  were  made  by  an 
expert.  A  fairly  typical  case  was  shown  by  Dr. 
Potts  at  the  meeting  of  the  Society  for  the  Study  of 
Disease  in  Children  in  Birmingham,  in  June,  1908, 
two  illustrations  of  which  we  now  reproduce,  f  This 
boy  required  education  in  a  special  school,  though 

*  See  Plate  II.,  Fig.  i,  p.  55.  f  See  Plate  X, 


74        MENTALLY  DEFICIENT  CHILDREN 


he  was  not  very  weak  mentally.  Contrary  to  what 
is  usual,  he  had  no  ocular  defect.  The  case  described 
by  Dr.  Rosa  Ford  in  the  Ophthalmoscope,  April,  1907, 
was  also  mentally  defective.  The  condition  has  been 
well  described  by  Patry*  in  a  monograph  published 
in  1905,  which  dealt  with  ten  cases  of  his  own,  and, 
in  addition,  with  the  records  of  fifty-eight  published 
cases.  Typical  cases  are  very  striking.  There  is  a 
dome-shaped  mound  rising  up  from  the  forehead, 
separated  from  the  temples  by  shallow  furrows;  the 
supra-orbital  ridges  are  absent,  and  the  eyes  prop- 
tosed  and  large.  At  the  same  time  there  is  an  atrophy 
of  the  optic  nerve,  post-neuritic  in  type.  The 
exophthalmos  is  due  to  malformation  of  the  orbit, 
the  upper  wall  of  which  slopes  down  towards  the  floor 
at  a  more  acute  angle  than  in  the  normal.  Many  of 
these  patients  suffer  greatly  from  headache;  some 
also  from  fits  during  childhood.  Patry  states  that 
the  cranial  deformity  commences  in  the  first  year  of 
life,  and  is  due  to  premature  synostosis  of  the  coronal 
and  frontal  sutures.  This  theory  receives  consider- 
able confirmation  from  the  deep  convolution  markings 
found  in  the  vault,  the  expanding  brain  being  driven 
up  into  the  vertex.  Hence  the  suggestion  that  these 
cases  would  be  benefited  by  craniectomy.  Patry 
endorses  Virchow's  view  that  the  primary  cause  both 
of  the  cranial  deformity  and  the  optic  neuritis  is  a 
meningitis. 

Emotional  shock,  such  as  fright  to  a  young  child 
confined  in  a  dark  cellar,  or  from  the  bite  of  a  dog, 
is  sometimes  assigned  as  a  cause  of  mental  defect. 

*  Contribution  d  I' Etude  des  Lesions  Oculaires  dans  les 
Malformations  Craniennes  sp&cialement  dans  l'Oxyc6phalie, 
par  Andre  Patry.  Paris,  1905. 


PATHOLOGICAL  CLASSIFICATION          75 


The  experimental  investigations  of  Dr.  G.  W.  Crile* 
have  shown  us  that  shock  and  fright  are  followed  by 
definite  changes  in  the  brain  cells,  as  shown  by  swell- 
ing and  rupture  of  the  nuclei,  the  cells  being  hyper- 
chromatic  during  fright,  and  exhausted  after.  It  is 
not  unreasonable  to  suppose  that  certain  cases  never 
return  to  their  normal  state.  Possibly,  too,  trophic 
changes,  brought  about  by  the  sympathetic  system, 
are  important  factors.  At  any  rate,  cerebral  atrophy, 
as  if  from  arrested  development,  is  found  in  some  of 
these  cases.  We  recognise  also  Toxic  cases,  such  as 
those  of  infants  drenched  with  alcohol  or  narcotics, 
in  which  the  interference  with  the  proper  nutrition 
of  the  nerve  elements,  and  the  poison  introduced, 
may  have  far-reaching  effects.  The  dangers  to 
infants  from  alcohol  are  very  real  and  very  frequent, 
as  all  readers  of  Mr.  George  R.  Sims'  spirited  article, 
"The  Cry  of  the  Children/'  reprinted  from  the 
Tribune,  must  admit.  Fortunately,  the  Children 
Act  now  excludes  infants  and  children  from  public- 
houses,  but  much  of  the  evil  still  remains.  There  is 
complete  ignorance  in  some  classes  of  the  harm  done 
to  nursing  mothers  by  the  taking  of  alcohol.  The 
time,  too,  is  more  than  ripe  for  some  legislation  which 
will  make  it  impossible  to  advertise  as  safe  for  children 
proprietary  medicines  which  contain  morphia  and 
other  narcotics. 

Under  the  title  of  Amaurotic  Family  Idiocy  some 
curious  and  hopeless  cases  of  infantile  cerebral  de- 
generation, with  symmetrical  changes  at  the  macula 
lutea,  commencing  about  three  months  after  birth,  and 
observed  almost  exclusively  among  Jewish  children, 
have  been  described  by  Sachs  of  New  York  and  other 

*  George  W.  Crile,  M.D.,  "  Anaesthesia  and  Anoci- Associa- 
tion," Surgery,  Gynaecology,  and  Obstetrics,  June,  1913. 


76        MENTALLY  DEFICIENT  CHILDREN 


American  authorities,  and  by  Mr.  Waren  Tay  and  Drs. 
Kingdon  and  Risien  Russell*  in  this  country.     The 
first  abnormalities  noticed  are  weakness  of  the  muscles 
of  the  back  and  neck,  and  imperfection  of  sight.    With 
the  ophthalmoscope  there  is  seen  in  the  macula  an 
oval  whitish-grey  patch,  with  softened  edges  slightly 
raised  above  the  general  surface  of  the  retina.     The 
fovea  centralis  appears  as  a  dark  cherry-red  spot  in 
the  centre  of  the  patch.     Later  on  there  is  optic 
atrophy,    and    complete    blindness.     The    senses    of 
taste  and  hearing  are  preserved,  the  latter  being  par- 
ticularly acute.     The   muscles  become  weaker  and 
weaker,  the  whole  body  becoming  involved.     There 
is  marked  emaciation,  and,  in  the  final  stages,  rigidity 
of  the  extremities,  with  retraction  of  the  head.   There 
is  no  fever.     The  thoracic  and  abdominal  organs  are 
normal.     The  cerebro-spiaal  fluid  shows  practically 
no  change.     Death  usually  occurs  in  less  than  two 
years,  from  pneumonia  or  cardiac  failure.     The  cause 
is  possibly  a  toxin,  causing  degeneration  of  the  cortical 
neurones,  the  optic  nerves,  and  the  pyramidal  tracts 
throughout  their  whole  course.     Dr.  Poynton,f  who 
has  also  written  on  the  subject,   after  seeing  four 
cases    and    studying    one    by    modern    neurological 
methods,  ascribes  the  condition  to  "  some  inherent 
bio-chemical    property    of    the    protoplasm    of    the 
cells."     He  states  that  the  disease  is  primarily  one 
of   the   interfibrillar   protoplasm    of   the    cells,    and 
describes  the  changes  in  the  nerve  cells  as  "  swelling 
of  the  cell  body  with  frequently  gross  alteration  in 
shape;    disappearance    of    Nissl    bodies;    excentric 
position  of  nuclei;  vacuolisation  of  the  protoplasm/' 

*  Med.  Chir.  Trans.,  vol.  Ixxx.,  p.  87. 

f  "  Amaurotic  Family  Idiocy,"  Brit,  Med.  Journal,  May  8  , 
X909,  p.  1106. 


PATHOLOGICAL  CLASSIFICATION         77 


In  one  case  Dr.  Mott  had  the  blood  and  cerebro- 
spinal  fluid  examined  for  the  Wasserrhann  reaction, 
with  a  negative  result,  thus  confirming  the  clinical 
experience  that  the  disease  is  not  a  result  of 
syphilis. 

The  condition  just  described  must  not  be  confused 
with  another  form  of  cerebral  degeneration  seen  in 
older  children,  known  as  Cerebral  Degeneration  with 
Symmetrical  Changes  in  the  Maculae.  This  also  is 
a  familial  disease,  and  is  thought  to  be  partly  due  to 
consanguinity  of  the  parents.  In  some  cases  syphilis 
has  been  a  factor,  but  has  not  been  in  evidence  in 
typical  cases  of  the  disease.  Children  who  are 
affected  are  normal  in  early  life,  and  make  a  good 
start  at  school.  At  the  age  of  six  or  seven  they  begin 
to  be  difficult,  fail  to  advance,  and  lose  the  power  of 
reading  ;  they  do  not  see  well,  and  it  is  noticed  that 
the  head  is  turned  to  the  side,  presumably  in  an 
effort  to  see  in  spite  of  the  central  scotoma  which  is 
believed  to  be  present.  There  is  obvious  mental 
deterioration,  with  the  development  of  dirty  habits, 
but  no  muscular  weakness  in  the  early  stages.  The 
distinguishing  feature  is  the  association  of  mental 
failure  with  a  curious  pigment ed  condition  round  the 
maculae.  The  disease  slowly  progresses,  the  child 
dying  in  seven  or  eight  years,  usually  from  some  inter- 
current  disease. 

Glandular  Inadequacy. — The  cases  just  considered 
are  due  to  the  presence  of  toxins.  We  now  pass  to 
an  important  group  which  are  due  to  the  absence 
of  a  necessary  element  from  the  economy.  Inade- 
quacy of  the  thyroid  and  other  glandular  secretions 
are  frequent  causes  of  serious  maldevelopment,  often 
associated  with  mental  defect.  The  best  known  of 
these  conditions  is  Cretinism,  the  full  development  of 


78        MENTALLY  DEFICIENT 

which  usually  takes  place  after  birth,  producing 
mental  deficiency.  Cretins  are  divided  into  two 
classes — endemic  and  sporadic.  Endemic  cretins  are 
met  with  in  goitrous  districts,  .and  in  affected 
families;  in  this  class  the  thyroid  is  often  enlarged, 
though  functionally  inactive.  Sporadic  cretins  are 
met  with  in  all  parts  of  the  world;  the  thyroid  is 
atrophied  or  altogether  absent. 

Intra-uterine    Cretinism    fully    developed     results 
usually  in  the  death  of  the  foetus,  which  displays  a 


FIG.  i. —  AMERICAN  CRETINS,  AGED  34  AND  24  YEARS. 
(J.  Moorhead  Murdoch,  M.D.) 

curious  stunted  conformation  of  the  body,  with  re- 
dundant skin,  thickened  cranial  bones,  and  imper- 
fectly formed  face.  The  essential  lesion  is  absence 
or  atrophy  of  the  thyroid  gland,  and  there  are  often 
found  fatty  tumours  in  the  supraclavicular  regions. 
Cases  of  sporadic  cretinism  usually  met  with  in  this 
country  differ  from  the  above  in  the  fact  that  the 
child  appears  normal  at  birth,  but  the  characteristic 


PATHOLOGICAL  CLASSIFICATION          7g 

conformation  and  mental  hebetude  are  gradually 
developed.  The  condition  can  usually  be  recognised 
at  six  months,  though  in  rare  instances  it  is  not 
possible  to  do  so  till  much  later,  sometimes  not  even 
till  the  child  is  six  or  seven  years  of  age.  Pro- 
gressive atrophy  of  the  thyroid  brings  about  a 
dwarfing  of  the  physical  growth  and  of  the  mental 
powers;  if  the  patient  arrives  at  adult  life,  he  still 
retains  the  bodily  and  mental  stature  of  a  child  (see 

!  Plate  XL,  Figs,  i  and  2). 

At  this  stage  we  may  consider  the  condition  of 
Infantilism,  some  varieties  of  which  are  due  to  dis- 
turbances of  the  functions  of  glands  of  internal 

:  secretion,  and  which  may  be  associated  with  men.tal 
defect.  The  term  merely  denotes  a  group  of  symp- 
toms. The  essential  feature  is  that  the  genital  organs 
remain  immature,  while  just  as  the  primary  sexual 
characteristics  of  adult  life  fail  to  appear  at  the 
proper  time,  so  also  do  the  secondary  sexual  charac- 
teristics of  body  and  mind.  In  some  cases  the  intelli- 
gence is  fairly  normal,  but  generally  it  is  weak  and 
childish.  Infantilism  is  not  as  a  rule  a  prominent 
feature  of  the  mentally  defective,  except  in  some 
cases  of  microcephalus,  mongolism,  and  severe  spastic 
diplegia.  Dr.  John  Thomson*  classifies  the  cases 
under  three  headings.  The  first  group,  which  he 
calls  the  Jdiopathic,  shows  no  serious  general  or 
local  disease.  In  the  second,  or  Cachectic,  serious 
general  disease  or  poisoning  exists.  The  most 
common  disease  is  chronic  tuberculosis,  next  syphilis ; 
malaria,  leprosy,  and  some  of  the  common  infective 
diseases,  have  also  been  blamed,  as  has  also  any  form 
of  heart  disease  that  begins  early  in  life,  and  causes 

*  "  Infantilism,"  System  of  Medicine,  Allbuttand  Rolleston, 
vol.  iv.,  part  i.,  p.  486. 


8o        MENTALLY  DBFlCtEMf  CHILDREN 


much  interference  with  the  general  circulation.  One 
type,  now  well  known  owing  to  the  writings  of  Dr. 
Herter,*  is  associated  with  intestinal  disorder,  usually 
with  coeliac  disease.  In  many  cases  of  infantilism 
polyuria  has  been  noticed;  sometimes  this  has  been 
due  to  diabetes  insipidus;  in  other  cases,  however,  as 
Dr.  Leonard  Parsonsj  and  others  have  shown,  the 
primary  lesion  is  interstitial  disease  of  the  kidneys. 
The  third  group  depends  on  gross  lesions  or  defects  of 
important  internal  organs.  The  organ  most  often 
at  fault  is  the  thyroid  gland,  and  Dr.  Thomson 
points  out  that  one  type  of  the  condition  constitutes 
the  mildest  degree  of  cretinism,  with  symptoms  so 
slight  that  the  real  cause  is  often  overlooked.  He 
brings  forward  evidence,  however,  to  show  that 
defective  action  of  other  internal  organs  may  produce 
the  same  symptoms.  The  account  of  two  cases  in 
which  the  pancreatic  secretion  was  proved  to  be 
in  abeyance,  and  in  which  development  resumed 
its  normal  course  on  the  regular  administration  of 
pancreatic  substance,  is  particularly  interesting. 
Dr.  Sajous  has  recently  called  attention  to  the 
frequent  association  of  aplasia  of  the  thymus  with 
defects  of  development,  and  its  absence  in  cases  of 
amentia,  as  recorded  by  Bourneville,  Morel,  and 
others.  J 

Pituitary  Infantilism  is  now  a  well-defined  variety; 
the  possible  connection  between  hypopituitarism  and 
some  forms  of  epilepsy  has  already  been  discussed. 
It  has  also  been  suggested  that  sometimes  the  supra- 

*  C.  Herter,  Trans.  Assoc.  Amev.  Phys.,  1908,  xxiii.,  p.  260. 

f  Leonard  Parsons,  M.D.,  "  Infantilism  associated  with 
Chronic  Interstitial  Nephritis,"  Lancet,  September  2,  1911. 

J  New  York  Med.  Journ.,  Jan.  to  Nov.,  1915  ("  Hema- 
denology  "). 


PATHOLOGICAL  CLASSIFICATION          81 

renal  glands  are  at  fault.  Dr.  A.  E.  Garrod*  refers 
to  a  case  in  which  a  marked  advance  in  development 
followed  the  administration  of  suprarenal  tablets. 
In  some  cases,  such  as  those  described  by  Dr.  Hastings 
Gilford,f  under  the  name  of  "  ateleiosis,"  the  under- 
lying cause  is  quite  obscure. 

Another  kind  of  defect  which  may  have  serious 
consequences  is  Sense-deprivation.  When  this  is 
associated  with  primary  mental  defect,  as  not  in- 
frequently happens,  the  difficulties  of  training  are 
greatly  increased;  if  both  sight  and  hearing  are 
absent,  attempts  at  education  must  inevitably  end 
in  failure.  If,  however,  the  mental  defect  is  due  to  the 
sense- deprivation,  then  proper  education  will  remove 
that  defect,  provided  it  is  begun  at  an  early  age. 
Should  it  be  unduly  delayed  or  altogether  neglected, 
permanent  secondary  amentia  may  be  the  result. 

In  conclusion,  we  may  briefly  sum  up  the  various 
secondary  types  of  mental  weakness,  the  pathological 
circumstances  of  which  we  have  described,  as  follows : 

A.  DEVELOPMENTAL  CASES: 

1.  Epiloia,  or  Tuberous  Sclerosis. 

2.  Eclampsic.  | 

3.  Epileptic. 

4.  Syphilitic  (inherited). 

5.  Paralyse  (spastic,  etc.). 

B.  ACCIDENTAL  OR  ACQUIRED: 

1.  Traumatic. 

2.  Post-febrile  (including  Oxycephaly). 

*  A.  E.  Garrod,  Diseases  of  Children,  edited  by  Garrod, 
Batten,  and  Thursfield,  p.  583. 

f  Hastings  Gilford,  The  Disorders  of  Postnatal  Groivth  and 
Development,  1911, 

6 


82        MENTALLY  DEFICIENT  CHILDREN 


3.  Emotional. 

4.  Toxic  (including  Amaurotic  Family  Idiocy 

and  Cerebral  Degeneration  with  Sym- 
metrical Changes  in  the  Maculae). 

5.  Due    to    Nutritional    Defect     (including 

Cretinism  and  Infantilism). 

6.  Due  to  Sense-deprivation. 

We  shall  find  that  these  divisions,  together  with 
those  of  the  primary  types  previously  given  (p.  64), 
will    be    serviceable    in    considering    points    in    tt 
etiology,    diagnosis,    and    prognosis    of    mental    de 
ficiency,  which  We  shall  proceed  to   discuss  in  the 
next  chapter. 


CHAPTER  V 
ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS 

IN  connection  with  mental  defect  in  children  there  is 
no  more  interesting  or  important  subject  than  its 
ETIOLOGY.  At  one  time  this  was  an  obscure  and 
difficult  problem,  but  such  considerable  'advance  has 
been  made  in  our  knowledge  in  recent  years  that  we 
are  now  in  a  position  to  express  a  more  decided 
opinion  than  heretofore,  and  to  say  that  in  primary 
amentia  a  neuropathic  inheritance  is  the  most  effec- 
tive factor.  In  a  limited  number  of  cases  other  in- 
fluences are  undoubtedly  accountable,  but  the  large 
majority  of  cases  of  primary  amentia  originate  in  this 
way,  and  even  in  secondary  amentia  a  morbid  heredity 
sometimes  has  an  important  influence  in  deciding  the 
issue.  These  views  were  foreshadowed  in  1892  by 
Dr.  Shuttleworth,  who  then  recorded  his  statistics  (in 
conjunction  with  those  of  Dr.  Fletcher  Beach)  in  an 
article  in  Hack  Tuke's  "  Dictionary  of  Psychological 
Medicine/'  in  which  1,200  cases  observed  at  the  Royal 
Albert  Asylum,  and  1.180  cases  at  Darenth  Asylum, 
were  collated.  Hereditary  mental  weakness  (insanity 
or  imbecility)  was  recorded  in  21-38  per  cent,  of  cases, 
but  in  addition  epileptic  or  neurotic  inheritance 
showed  a  percentage  of  20,  making  a  total  of  41-38 
per  cent,  of  cases  which  could  be  tabulated  as  having 
a  neuropathic  inheritance,  a  proportion  which  tends 
to  increase  with  further  knowledge  of  the  antecedents. 

83 


84        MENTALLY  DEFICIENT  CHILDREN 


Dr.  Caldecott  of  Earlswood  Asylum  found  that  over 
70  per  cent,  of  his  patients  have  neuropathic  ante- 
cedents. "  In  Germany,  Koch  came  to  the  con- 
clusion that  it  accounted  for  60  per  cent,  of  cases. 
In  Switzerland  (Canton  of  Berne),  the  census  of  1893 
showed  that  heredity  was  present  in  55  per  cent,  of 
idiots;  whilst  in  Norway,  Ludwig  Dahl  found  it  to 
occur  in  50  per  cent,  of  cases."*  It  is  important  to 
remember  that  in  Dr.  Shuttleworth's  inquiry,  as  in. 
most  of  the  earlier  ones,  no  house-to-house  visitation 
was  made  in  order  to  elicit  additional  information, 
and  to  examine  both  the  parents.  When  this  pro- 
cedure has*  been  adopted,  and  searching  inquiries 
made  into  the  family  records,  convincing  evidence  of 
the  effects  of  a  morbid  heredity  has  always  been 
obtained.  One  of  the  most  careful  inquiries  on  these 
lines  was  conducted  by  Dr.  Tredgold,  f  who  studied 
a  large  number  of  cases  in  the  pauper  asylums  of 
London,  and  in  150  obtained  "  full  particulars  of  the 
family  for  at  least  three,  and  sometimes  four,  genera- 
tions." He  traced  a  neuropathic  inheritance  in  82-5 
per  cent.  All  those  who  have  conducted  an  inquiry 
of  this  kind  will  agree  with  Dr.  Tredgold  that  the 
reason  why  he  obtained  a  considerably  higher  per- 
centage than  most  other  observers  is  "  entirely  a 
question  of  the  method  adopted."  "  Again  and 
again,"  he  says,  "  have  I  discovered  by  a  little  ques- 
tioning a  well-marked  history  of  insanity,  of  which 
no  record  whatever  existed  in  the  case-books.  The 
taking  of  a  reliable  family  history  involves  much  time 
and  trouble.  Several  members  of  the  family  must  be 

*  A.  F.  Tredgold,  Mental  Deficiency,  1914,  p.  40. 

j  A.  F.  Tredgold,  Report  and  Evidence  of  the  Royal  Com- 
mission on  the  Care  and  Control  of  the  Feeble-minded,  1908, 
vol.  i.,  p.  396. 


DIAGNOSIS.  AND  PROGNOSIS   85 

seen,  and  their  confidence  must  be  gained  before  any- 
thing like  the  true  state  of  affairs  can  be  elicited.  It 
is  not  only  that  the  relatives  are  averse  from  giving 
information  upon  what  they  regard  as  their  private 
affairs  to  a  complete  stranger,  but  that  very  often 
they  do  not  really  know  until  they  have  talked  the 
matter  over  amongst  themselves."  We  may  add 
that  it  is  extraordinary  how  ignorant  even  well- 
educated  people  often  are  as  to  the  records  of  illness 
and  causes  of  death  of  their  forbears.  In  the  case  of 
insanity  and  consumption,  in  particular,  it  is  a  com- 
mon practice  to  gloss  over  the  real  nature  of  the 
trouble,  and  keep  many  members  of  the  family  in 
complete  ignorance. 

Dr.  Tredgold's  statistics  have  been  amply  confirmed 
by  the  inquiries  in  America  of  Dr.  Goddard,  the 
Director  of  the  Research  Laboratory  of  the  Training 
School  at  Vineland,  New  Jersey,  for  Feeble-minded 
Girls  and  Boys.  At  this  institution  a  laboratory  and 
Department  of  Research  for  the  study  of  feeble- 
mindedness was  opened  in  September,  1906;  since 
1910  it  has  employed  field-workers.  "  These  are 
women  highly  trained,  of  broad  human  experience, 
and  interested  in  social  problems.  As  a  result  of 
weeks  of  residence  at  the  Training  School,  they  be- 
come acquainted  with  the  condition  of  the  feeble- 
minded. They  study  all  the  grades,  note  their  pecu- 
liarities, and  acquaint  themselves  with  the  methods 
of  testing  and  recognising  them.  They  then  go  out 
with  an  introduction  from  the  Superintendent  to  the 
homes  of  the  children,  and  there  ask  that  ah1  the  facts 
which  are  available  may  be  furnished,  in  order  that 
we  can  know  more  about  the  child  and  be  better  able 
to  care  for  him,  and  more  wisely  train  him. 

"Sometimes  all  necessary  information  is  obtained 


86        MENTALLY  DEFICIENT  CHILDREN 


from  the  one  central  source,  but  more  often,  especially 
where  the  parents  are  themselves  defective,  many 
visits  to  other  homes  must  be  made.  Parents  often 
send  the  field-worker  to  visit  near  and  distant  rela- 
tives, as  well  as  neighbours,  employers,  teachers, 
physicians,  ministers,  overseers  of  the  poor,  alms- 
house  directors,  etc.  These  must  be  interviewed, 
and  all  the  information  thus  obtained  must  be 
weighed  and  much  of  it  verified  by  repeated  visits  to 
the  same  locality,  before  an  accurate  chart  of  the  par- 
ticular child's  heredity  can  be  made/'  * 

As  a  result  of  this  work,  Dr.  Goddard  has  been  able 
to  study  more  than  300  families.  His  conclusions 
are  that  "  Feeble-mindedness  is  hereditary,  and  trans- 
mitted as  surely  as  any  other  character."  Dr.  God- 
dard's  researches  have,  however,  gone  further  than 
this,  for  he  claims  to  have  shown  that,  putting  mon- 
golianism  on  one  side,  mental  defect  is  a  Mendelian 
recessive  character.  As  a  consequence,  not  every 
person  who  carries  the  taint  shows  it,  as  would  happen 
if  mental  defect  were  a  Mendelian  dominant  charac- 
teristic; many  people  unconsciously  carry  the  taint 
in  their  germ-cells  without  showing  any  sign;  it  only 
becomes  evident  in  certain  members  of  the  families 
where  both  parents  have  a  mentally  defective 
heredity.  "  According  to  a  recent  calculation,  made 
in  one  of  the  bulletins  of  the  Eugenics  Record  Office, 
about  one-third  of  the  population  in  the  United  States 
is  thus  capable  of  conveying  mental  deficiency,  the 
1  insane  tendency/  epilepsy,  or  some  other  defect/'  f 

*  H.  H.  Goddard,  Ph.D.,  The  Kallikak  Family  :  a  Study 
in  the  Heredity  of  Feeble-mindedness.  New  York:  The  Mac- 
millan  Company,  1912.  Also  Feeble-mindedness  :  Its  Causes 
and  Consequences.  New  York:  The  Macmillan  Company 

1914- 

f  C.  W.  Saleeby,  M.D.,  The  Progress  of  Eugenics,  p.  181. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS     87 

It  is  not  necessary  for  us  to  elaborate  the  details 
of  Mendelism,  as  there  are  now  so  many  excellent 
treatises  on  the  subject;  for  the  benefit,  however,  of 
those  of  our  readers  who  are  not  thoroughly  familiar 
with  its  principles,  we  may  briefly  state  how  it  works 
out  as  regards  mental  defect  in  various  sets  of  cases : 

1.  If  two  normal  parents,  both  of  whose  families  are 
free   from  mental   defect,   have   children,    all   those 
children  will  be  normal;  and,  in  addition,  the  children 
will  be  incapable  of  transmitting  mental  defect  to 
their  offspring. 

2.  If  a  normal  person  whose  family  is  quite  free 
marries  either  a  mentally  defective  person  or  one  who, 
though  normal,  is  a  carrier  of  the  defect,  then,  al- 
though all  the  children  will  be  normal,   a  certain 
number  will  be  carriers  of  the  taint.     If  the  second 
parent  is  actually  defective,  half  the  children  will 
carry  it;  but  if  the  second  parent  merely  carries  it, 
without  showing  it,  only  one  in  every  four  of  the 
children  will  carry  the  defect  in  its  germ- cells. 

3.  If  both  parents  are  apparently  normal,  and  yet 
both  carry  the  taint,  then  one  in  every  four  of  their 
children  will  be  defective,  and,  in  addition,  two  out 
of  every  three  of  the  normal  children  will  carry  the 
defect,  while  one  only  will  be  entirely  free. 

4.  If  both  parents  are  defective,  every  one  of  the 
children  will  be  defective. 

In  human  families,  which  are  limited  in  size,  the 
numbers  of  those  who  are  defective  and  those  who 
are  not  seldom  corresponds  exactly  with  the  table 
just  given;  the  results  of  Mendelian  inheritance  can 
only  be  exact  when  the  families  are  large,  as  happens 
in  the  vegetable  kingdom.  Yet  many  of  Dr.  God- 
dard's  records  approximate  closely  to  the  condi- 
tions of  a  Mendelian  recessive. 


MENTALLY  DEFICIENT  CHILDREN 


Further  confirmation  from  other  workers  is  re- 
quired before  this  theory  can  be  accepted  uncondition- 
ally; still,  the  work  of  Dr.  Goddard  has  been  so 
thorough  and  extensive,  and  the  explanation  fits  in 
so  well  with  generally  observed  phenomena,  that 
authority  is  attached  to  his  conclusions. 

The  work  done  in  the  Galton  Laboratory  by  Pro- 
fessor Karl  Pearson  and  his  collaborators,  the  writings 
of  Whetham  and  many  others,  have  established  the 
importance  of  heredity  in  regard  to  mental  defect. 
One  argument  of  which  much  was  made  by  the  school 
who  attributed  everything  to  environment  was  the 
results  of  matings  in  the  class  of  cases  described  in 
heading  3  in  the  table  above — that  is,  those  instances 
when  two  normal  parents  have  a  certain  proportion 
of  defective  children.  At  one  time  it  was  difficult  to 
reconcile  this  with  the  hereditary  principle,  but,  ac- 
cording to  Goddard's  theory  that  mental  defect  is 
a  recessive  Mendelian  quality,  this,  so  far  from  dis- 
proving thelmportance  of  heredity,  goes  a  long  way 
to  establish  it.  The  most  important  evidence,  how- 
ever, of  the  powerful  effect  of  heredity  is  afforded 
by  the  fourth  condition  described  above ;  this  is  abso- 
lutely true.  In  the  year  1909  the  statement  was  first 
made  that  two  mentally  defective  parents  never  have 
any  but  defective  offspring;  in  the  six  years  that 
have  since  elapsed  this  statement  has  never  been 
contradicted. 

It  is  necessary  to  point  out  that  if  mental  defect  is 
a  Mendelian  recessive  character,  segregation  cannot 
stamp  it  out  in  a  generation ;  the  good  effect  of  segre- 
gation will  only  gradually  become  apparent.  The 
Mendelian  theory  explains  the  deep-rooted  objection 
to  cousin  marriages,  the  danger  being  that  if  one 
parent  carries  mental  defect  in  his  germ-cells,  the 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS     8g 


other  parent  will  very  likely  do  so  too ;  the  results  of 
such  a  union  are  sometimes  disastrous.  The  Men- 
delian  theory  enables  us  also  to  understand  how  a 
parent  may  have  only  normal  children  after  one 
marriage,  and  defective  children  after  a  second 
marriage;  the  writer  has  recently  seen  a  normal 
woman  who  had  four  normal  children  by  her  first 
husband,  but  after  a  second  marriage  four  children, 
of  whom  only  one  was  normal,  while  one  was  defective 
and  two  died  in  infancy.  The  explanation  is  that 
the  mother  is  a  carrier  of  mental  defect,  and  that  the 
first  husband  was  free,  while  the  second  is  a  carrier. 
The  history  of  the  Kallikak  family,  unearthed  by 
the  energy  of  Dr.  Goddard,  shows  how  a  man  by 
different  matings  may  found  two  entirely  different 
types  of  family. 

We  must  not,  however,  pursue  this  interesting 
aspect  of  the  subject  further,  but  must  proceed  to  say 
that,  although  we  attach  the  greatest  importance  to 
heredity,  we  believe  that  the  environment  does  exert 
an  influence;  in  considering  various  factors  that  one 
sometimes  finds  to  be  precursors  of  mental  defect,  we 
shall  later  on  give  specific  examples  where  the  en- 
vironment was  undoubtedly  to  blame.  Speaking 
generally,  we  accept  the  doctrine  that  "  like  breeds 
like/'  and  admit  that  the  germ-cells  are  wonderfully 
protected  from  injurious  influences.  There  are,  how- 
ever, many  observations  as  regards  both  the  vegetable 
and  animal  kingdoms  which  show  that  external  influ- 
ences may  leave  a  mark.  For  instance,  Macdougal,* 
experimenting  with  the  evening  primrose,  showed 
that  by  injecting  certain  chemical  substances  into  the 
immature  ovaries,  he  got  seeds  which  afforded  plants 

*  Report  of  the  Department  o  Botanical  Research,  Fifth 
Year-Book,  Carnegie  Institute,  Washington,  1907,  p.  119. 


90        MENTALLY  DEFICIENT  CHILDREN 


some  of  which  departed  widely  from  type;  in  this 
way  he  was  able  to  establish  new  varieties.  Tower,* 
experimenting  with  a  certain  species  of  beetle,  ob- 
served that  if  shortly  before  maturation  of  the  germ- 
cells  he  subjected  the  beetles  to  intense  environmental 
change  (cold  and  humidity),  he  obtained  offspring 
widely  different  from  the  parents,  and  the  results 
appeared  to  be  permanent,  or  at  least  heritable 
through  further  generations.  The  wing-cases  of  the 
normal  beetle  showed  one  pattern,  those  of  the 
progeny  of  the  cooled  beetles  showed  another.  When 
crossed,  these  altered  forms  bred  true,  nor  did  they 
lose  their  acquired  characters  in  subsequent  genera- 
tions. Sumnerf  also  proved  that  influences  primarily 
affecting  the  body  can  secondarily  affect  the  germ- 
cells.  He  found  that  similar  broods  of  young  mice 
brought  up,  one  in  a  warm  temperature  (21°  C.),  and 
the  other  in  a  cold  temperature  (5°  C.),  differ  consider- 
ably; the  mean  length  of  tail,  feet,  and  ears  of  those 
brought  up  in  the  warm  atmosphere  is  greater,  and 
the  young  of  these  two  groups,  though  reared  in  a 
common  room,  subsequently  present  the  greater  or 
lesser  length  of  tail,  foot,  and  ear  acquired  by  the 
parent.  Again,  Carriere  J  inoculated  guinea-pigs, 
both  male  and  female,  with  the  toxins  and  soluble 
products  of  tubercle  bacilli,  and  found  that  the  num- 
bers of  the  litters  were  reduced  and  the  number  of 
the  stillborn  increased.  Lustig§  showed  similar  re- 
sults with  chickens;  there  was  diminished  fertility, 

*  An  Investigation  of  Evolution  in  Chrysomelid  Beetles  oj 
the  Genus  Leptinotana  (publication  of  the  Carnegie  Institute), 
Washington,  1906. 

f  Archiv  fur  Entwickelungsmechanik ,  30,  1910. 

J  Archives  de  Medecine  Experimental,  12,  1900,  p.  782. 

§  Centralblatt  fur  Pathologic,  xv.,  1904,  p.  210. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS     gi 


an  increased  number  of  monstrous  births,  and  poor 
vitality  of  the  surviving  offspring. 

Such  observations  as  these  justify  the  contention  of 
Dr.  Beard,*  in  his  "  Study  of  the  Morphological  Con- 
tinuity of  Germ-Cells  as  the  Basis  of  Heredity  and 
Variation/'  that  food,  climate,  toxins,  disease,  natural 
phenomena  of  all  kinds,  can  affect  the  corresponding 
characters  of  any  germ-cell.  Dr.  Beard  demonstrated 
that  at  the  time  at  which  the  determiners  separate 
out  of  the  germ-cells,  the  reaction  to  the  influences  of 
the  environment  is  a  cause  of  variation  and  varieties ; 
healthy  influences  promote  variation  of  a  good  type, 
unfavourable  ones  tend  towards  a  bad  type.  More 
than  half  a  century  ago  records  were  published 
proving  that  poisons  such  as  lead,  mercury,  alcohol, 
malaria,  smallpox,  or  tubercle,  in  very  concentrated 
doses  are  possible  causes  of  mental  defect  in  the 
human  family.  Constantin  Paulf  stated  that  of 
32  pregnancies  in  which  the  husband  alone  was  ex- 
posed to  lead  in  his  work,  there  were  12  abortions; 
and  of  the  20  children  born,  8  did  not  survive  the 
first  year,  4  died  in  the  second,  and  5  in  the  third,  so 
that  only  3  out  of  32  lived  beyond  the  third  year. 
He  also  showed,  as  Roque,  Sir  Thomas  Oliver,  and 
others  have  done  since,  that  epilepsy,  idiocy,  and 
imbecility  frequently  occur  in  the  children  of  workers 
in  lead.  LizeJ  supplied  identical  data  regarding 
workers  exposed  to  the  fumes  of  mercury.  We  could 
quote  many  more  facts  such  as  these,  which  prove 

*  J.  Beard,  "  A  Morphological  Continuity  of  Germ-Cells 
as  the  Basis  of  Heredity  and  Variation,"  Review  of  Neurology 
and  Psychiatry,  vol.  ii  ,  1904. 

f  Constantin  Paul,  Archives  Generates  de  Medecine,  15. 
1860,  p.  513. 

%  Lize,  Union  Medicale,  1862,  p.  106. 


92        MENTALLY  DEFICIENT  CHILDREN 


that  variation  is  sometimes  due  to  the  environment 
and  mode  of  life  of  the  parent,  and  that  variation 
may  take  the  form  of  mental  defect. 

When  investigating  at  Stoke-upon-Trent  for  the 
Royal  Commission  on  the  Care  and  Control  of  the 
Feeble-minded,  Dr.  Potts  found  several  cases  of  ab- 
normally backward  children.  In  several  instances 
these  children,  after  being  almost  hopeless  at  school 
for  many  months,  unexpectedly  improved,  and  sub- 
sequently developed  as  well  as  their  normal  fellows. 
He  attributed  the  condition  partly  to  the  mothers 
going  out  to  work  and  leaving  the  children  shut  up 
for  many  hours,  ill  supplied  with  food,  and  with  no  one 
to  talk  to  or  play  with.  When  such  children  come  to 
school,  they  sometimes  actually  have  to  be  taught 
to  talk,  and  much  else  that  a  child  should  learn  at 
home. 

It  is  time  now  to  discuss  certain  special  factors 
which  are  sometimes  accountable,  in  whole  or  in  part, 
for  mental  defect.  We  must  first  point  out,  however, 
that  it  is  not  logical  to  attribute  to  a  single  specific 
cause,  other  than  a  direct  hereditary  tendency,  the 
majority  of  cases  met  with,  inasmuch  as  on  investiga- 
tion we  olten  discover  several  contributory  factors. 
So  strong,  indeed,  is  the  tendency  of  Nature  to  revert 
to  a  healthy  type,  that  the  solitary  infraction  of 
physiological  law  is  not  often  visited  with  the  penalty 
of  mental  abnormality;  if  we  only  look  back  far 
enough,  we  shall  probably  find  that  such  a  culmina- 
tion is  reached  by  the  gradations  of  repeated  trans- 
gressions. Not  every  drunken  parent  procreates  an 
idiot;  but  when  inherited  nervous  instability  from 
this  or  other  causes  is  intensified  in  the  next  genera- 
tion by  injudicious  marriage,  or  by  unfavourable 
environment,  or  by  a  very  severe  infectious  illness 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS     93 


shortly  before  conception,  instances  of  mental  de- 
generacy are  apt  to  occur. 

We  shall  first  consider  Inherited  Syphilis.  This 
has  recently  been  shown  to  act  more  frequently  as  a 
cause  than  was  suggested  by  the  earlier  records.  Dr. 
Mott  has  studied  for  several  years  the  effects  of 
syphilis,  acquired  and  congenital,  on  the  nervous 
system,  and  arrived  at  the  conclusion  that  it  is  an 
active  agent  in  the  production  of  congenital  weakness 
and  the  degeneracy  that  accompanies  it.  He  has 
demonstrated  that  "  the  measure  of  the  effects  of 
syphilis  in  the  production  of  feeble-mindedness  and 
epilepsy  should  not  be  estimated  only  by  the  cases  in 
which  there  are  visible  and  characteristic  signs  of 
syphilis  on  the  body,  for  he  has  observed  one  member 
of  a  family  with  syphilitic  notched  teeth,  another 
without  any  external  sign,  but  with  severe  visceral 
and  brain  disease,  while  a  third  was  an  imbecile.  He 
has  also  seen  many  other  examples  pointing  to  the 
same  conclusion/'  Dr.  Mott*  further  states  that 
"  it  may  be  thought  that  because  syphilis  of  the 
parents  produces  sterility,  miscarriage,  and  abortion, 
its  dangers  are  greatly  minimised,  but  it  cannot  be 
doubted  that  if  the  poison  is  sufficiently  strong  to 
kill  the  embryo  either  before  or  shortly  after  birth, 
it  must  have  a  devitalising  effect  on  the  offspring  that 
survives.  Though  hereditary  neurosis  or  psychosis 
greatly  increases  the  liability  of  the  syphilitic  poison 
to  affect  the  nervous  system,  yet  in  numbers  of  the 
cases  there  was  no  pre-existing  neuropathic  family 
history — in  fact,  sometimes  the  syphilitic  poison 
appeared  to  induce  a  neuropathic  condition  in  the 
offspring/'  Dr.  Mott  has  also  shown  that  in  some  cases 

*  F.  W.  Mott,  Minutes  of  Evidence  taken  before  the  Royal 
Commission  on  the  Care  and  Control  of  the  Feeble-minded, 
vol.ju  p.,  453- 


94        MENTALLY  DEFICIENT  CHILDREN 

the  blindness,  deafness,  mental  deficiency  or  disease 
does  not  manifest  itself  till  between  eight  and  puberty. 

More  recently  confirmatory  evidence  of  the  pro- 
duction of  mental  defect  by  inherited  syphilis  has 
been  obtained  by  means  of  the  Wassermann  reaction. 
The  results  obtained,  however,  by  different  investiga- 
tors differ  so  much  that  we  cannot  regard  any  of  them 
as  final.  The  table  on  p.  95,  showing  the  percentage 
of  cases  of  congenital  mental  defect,  found  to  give  a 
positive  Wassermann  reaction  by  some  of  the  workers, 
justifies  this  statement. 

Well  might  Sir  H.  Bryan  Donkin  say  that,  "  even 
assuming  that  the  Wassermann  process  may  be 
regarded  as  an  absolute  scientific  test  for  the  presence 
of  syphilitic  infection,  it  is  clear  that  at  present  no 
positive  conclusion  as  to  the  relations  of  mental 
defect  to  syphilis  can  be  drawn  from  any  accounts 
hitherto  published  "*  The  discrepancies  in  the 
results  obtained  are  partly  due  to  the  different 
antigens  and  degrees  of  dilution  employed  by  different 
investigators.  The  age  of  the  mentally  defective 
person  also  affects  the  result,  a  larger  number  of 
positive  reactions  being  obtained  in  early  life.  But 
even  if  the  largest  percentage  yet  obtained  were 
proved  to  be  correct,  it  would  not  shake  our  belief 
in  the  outstanding  importance  of  a  morbid  heredity. 
It  need  prove  nothing  more  than  that  the  mentally 
defective,  including,  of  course,  slight  cases,  are  singu- 
larly lacking  in  moral  control  and  ability  to  take 
care  of  themselves.  Our  verdict  at  the  present  time 
is  that,  as  regards  the  causation  of  mental  defect, 
syphilis  is  a  sufficient  factor  in  itself,  and  often  has 
a  deciding  influence  when  there  is  a  morbid  heredity 
or  other  unfavourable  factors. 

*  Sir  H,  Bryan  Donkin,  M.D.,  Lancet,  March  14,  1914. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS     95 

PERCENTAGE  OF  POSITIVE  REACTIONS  TO  THE  WASSERMANN 
TEST  OBTAINED  BY  VARIOUS  WORKERS. 

Thomsen,  Boas,  Hort,  and  Leschly1        . .      1*5  per  cent. 

Dawson2        ..4-0 

Kellner,  Clemenz,  Bruckner,  and  Rauten- 

burg3          ....  . .      7*4 

Lippmann  (first  series)4      .  .          . .          . .      8-9 

Rees  Thomas5          10-0 

Lippmann  (second  series)  ..          ..  13-2 

Atwood6        ....  . .  14*6 

Dean7  . .  i5'4 

Gordon8         . .  16*5 

Krober9         21-3 

Raviart,     Breton,      Petit,      Gayet,      and 

Cannae10 3°'8 

Scholberg  and  Goodall11 32-6         „ 

Chislett12 50-0 

Fraser  and  Watson13  . .          . .          . .  6o»o         ,, 

1  Thomsen,   Boas,   Hort,   and  Leschly,  Berliner  Klinische 
Wochenschrift,  1911,  Band  xlviii.,  p.  891. 

2  Dawson,  Journal  of  Psycho- Asthenics,  Faribault,  Minne- 
sota, December,  1912. 

:{  Kellner,  Clemenz,  Bruckner,  and  Rautenburg,  Deutsche 
Medicinische  Wochenschrift  (Leipzig  und  Berlin),  1909,  p.  1827. 

4  Lippmann,  Munchener  Medicinische  Wochenschrift,  1909, 
Band  Ivi.,  p.  2417. 

5  Rees  Thomas,  Lancet,  April  4,  1914. 

6  Atwood,  Journal  of  American  Medical  Association,  Chi- 
cago, vol.  lv.,  p.  464. 

7  Dean,  Proceedings  of  the  Royal  Society  of  Medicine,  Neuro- 
logical Section,  vol.  in'.,  No.  9,  July,  1910. 

8  Gordon,  Lancet,  September  20,  1913. 

9  Krober,  Medicinische   Klinik,  Vienna,  1911,  Band   vii., 

P-  I239- 

10  Raviart,   Breton,   Petit,  Gayet,  and  Cannae,  Revue  de 
Medecim,  Paris,  1909,  an.  xxviii.,  p.  840. 

11  Scholberg    and    Goodall,    Journal    of    Mental    Science, 
vol.  Iviii.,  No.  237,  April,  1911,  p.  247. 

12  Chislett,  Ibid.,  vol.  Ivii.,  No.  238,  July,  1911,  p.  499. 

13  Fraser  and  Watson,  Ibid.,  vol.  lix.,  No.  247,  October, 
1913,  p.  640, 


96          MENTALLY  DEFICIENT  CHILDREN 


A  phthisical  family  history  has  often  been  blamed 
in  the  past  for  mental  defect;  at  the  present  time 
there  is  a  difference  of  opinion  as  to  how  far  tuber- 
cular disease  acts  in  its  causation,  some  authorities 
believing  that  it  acts  directly,  while  others  regard  it 
rather  as  a  concomitant  of  degeneracy  to  be  found 
along  with  various  degrees  of  amentia  in  families  on 
the  racial  down-grade.  Thus,  Sir  James  Crichton- 
Browne,  when  giving  evidence  before  the  Royal  Com- 
mission on  the  Care  and  Control  of  the  Feeble- 
minded, said:  "  The  true  connection  between  tuber- 
culosis and  mental  defect  is  to  be  found  in  the  fact 
that  they  are  both  apt  to  fasten  on  a  particular  kind 
of  human  soil,  weakly  and  little  resistant  to  morbific 
agents."*  While  giving  due  weight  to  this  idea, 
we  are  probably  justified  in  concluding  with  Dr. 
Tredgoldf  that  "  in  the  absence  of  neuropathic  in- 
heritance, consumption  and  alcoholism,  if  very  strongly 
marked,  may  produce  mental  defect." 

How  far  parental  intemperance  is  accountable  has 
given  rise  to  much  controversy.  In  a  paper  read 
before  the  Society  for  the  Study  of  Inebriety  (London) 
in  October,  1908,  Dr.  PottsJ  made  a  careful  review  of 
the  evidence  as  to  how  far  alcoholism  in  a  pre- 
vious generation  was  accountable.  He  cited  many 
authenticated  cases  where  it  appeared  to  be  a  direct 
cause,  and,  in  particular,  one  quoted  by  the  late  Dr. 

*  Sir  James  Crichton-Browne,  M.D.,  Report  and  Evidence 
of  the  Royal  Commission  on  the  Care  and  Control  of  the  Feeble- 
minded, 1908,  vol.  i.,  p.  329.  y 

f  A.  F.  Tredgold,  Report  and  Evidence  of  the  Royal  Com- 
mission on  the  Care  and  Control  of  the  Feeble-minded,  1908, 
vol.  i.,  p.  396. 

J  W.  A.  Potts,  "The  Relation  of  Alcohol  to  Feeble- 
mindedness," British  Journal  of  Inebriety,  January,  1909. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS     97 

Andriezen*  of  a  man  aged  twenty-two,  the  second 
child  of  a  family  of  six.  This  individual  was  begotten 
by  his  father  while  in  a  state  of  "  alcoholic  intoxica- 
tion and  exaltation.  The  child  was  neurotic,  and  at 
twenty-two  had  to  be  admitted  to  an  asylum  suffering 
from  dementia  prcecox.  The  father,  a  well-to-do  man, 
had  several  mistresses,  and  was  the  father  of  several 
other  children.  Though  given  to  occasional  alcoholic 
indulgence,  he  abstained  from  cohabiting  when  in  a 
state  of  intoxication,  and  his  other  children,  born  of 
his  sober  moments,  were  not  afflicted  mentally  or 
bodily  like  the  patient  referred  to."  Attention  was 
directed  in  this  paper  to  the  important  comparative 
statistics  of  Dr.  Sullivan  and  others,  and  especially 
to  the  investigation  of  Dr.  MacNicholl  in  New  York. 
This  inquiry,  undertaken  for  the  New  York  Academy 
of  Medicine  in  1901,  recorded,  among  other  observa- 
tions, the  results  of  tracing  the  family  histories  of 
3,711  children  through  three  generations,  with  great 
detail  in  regard  to  the  taking  of  alcohol.  Dividing 
them  into  two  classes — viz.,  those  free  from  hereditary 
alcoholic  taint  and  those  with  that  taint — it  was 
found  that  of  those  free  from  hereditary  alcoholic 
taint,  96  per  cent,  were  proficient,  4  per  cent,  were 
dullards,  and  18  per  cent,  suffered  from  some  neurosis 
or  organic  disease.  On  the  other  hand,  of  those  with 
hereditary  alcoholic  taint,  23  per  cent,  were  proficient, 
77  per  cent,  were  dullards  (and  of  these  more  than 
one-third  were  very  deficient),  and  76  per  cent,  suf- 
fered from  some  neurosis  or  organic  disease. 

The  conclusions  drawn  at  the  end  of  the  paper  are 
that  "  the  evidence  is  not  clear  that  alcoholism  by 

*  W.  Lloyd  Andriezen,  "  The  Problem  of  Heredity,  with 
Special  Reference  to  the  Pre-Embryonic  Life/'  Journal  of 
Mental  Science,  January,  1905. 

7 


98         MENTALLy  DEFICIENT 


itself  in  the  father  will  produce  amentia,  but  it  is 
quite  plain  that  in  combination  with  other  bad 
factors  it  is  a  most  unfavourable  element,  while 
maternal  drinking,  and  drinking  continued  through 
more  than  one  generation,  are  potent  influences  in 
mental  degeneracy." 

In  many  cases  in  which  alcoholism  appears  at  first 
sight  to  be  the  determining  factor,  the  alcoholism  is 
really  a  neurosis,  and  is  simply  evidence  of  a  morbid 
heredity.  Sometimes,  however,  excessive  drinking 
is  deliberate  self-indulgence,  the  consequences  of 
which  may  be  very  serious  to  the  offspring.  There 
is  no  gainsaying  this  fact,  although  Professor  Karl 
Pearson*  claims  to  have  proved  that  alcoholic  in- 
dulgence in  the  mass  has  no  deteriorating  influence  on 
the  physique  and  ability  of  the  following  generation  ; 
his  statistics  and  conclusions  have,  however,  been  sub- 
jected to  much  criticism.  The  problem  is  beset  with 
difficulties  ;  to  settle  the  question  finally,  we  require 
in  statistics  very  careful  investigation  as  to  whether 
there  was  any  sign  of  morbid  heredity  before  the 
drinking  began,  and,  of  course,  a  statement  as  to 
whether  the  drinking  preceded  the  birth  of  the  child. 
The  only  comparisons  of  real  value,  are  between  total 
abstainers  and  drinkers;  any  arbitrary  division  be- 
tween moderate  and  excessive  drinkers  begs  the 
question.  Dr.  Shuttleworth  'and  others  have  fre- 
quently pointed  out  that  it  is  also  necessary  to  go 
back  more  than  one  generation;  it  is  no  uncommon 
experience  to  find  that  the  child  of  a  heavy  drinker 
shows  no  abnormality  beyond  a  want  of  nervous  tone 

*  A  First  Study  of  the  Influence  of  Parental  A  Icoholism  on 
the  Physique  and  Ability  of  the  Offspring,  by  Ethel  M.  Elderton, 
with  the  assistance  of  Karl  Pearson,  F.R.S.  Eugenic  Lab-* 
oratory  Memoirs.  London:  Dulau  and  Co.,  1910. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS 


and  tendency  to  eccentricity  when  he  grows  up;  his 
eccentricity  may  take  the  form  of  being  a  rabid  tem- 
perance advocate,  but  when  one  of  his  children  ex- 
hibits mental  defect,  that  does  not  indicate  that  tem- 
perance is  no  benefit,  but  rather  that  the  grand- 
father's indulgence  has  had  far-reaching  effects. 

Dr.  Shuttleworth's  statistics,  published  in  1892, 
showed  that  a  number  of  cases,  almost  30  per  cent., 
are  attributed  by  the  parents  to  maternal  ill-health, 
accident,  or  shock  during  gestation.  More  recent 
investigations,  such  as  those  of  Dr.  Tredgold  and  Dr. 
Goddard,  have  shown  that  when  a  house-to-house 
visitation  is  made,  and  inquiries  as  regards  all  mem- 
bers of  the  family,  there  are  often  in  these  cases  clear 
evidences  of  a  morbid  heredity.  We  have,  however, 
already  cited  experiments  in  both  the  vegetable  and 
animal  kingdoms,  and  special  histories  of  human 
beings,  which  show  that  it  is  only  reasonable  to  suppose 
that  these  conditions  may  exact  their  toll.  Dr.  Mercier 
and  others,  when  giving  evidence  before  the  Royal 
Commission  on  the  Care  and  Control  of  the  Feeble- 
minded, gave  it  as  their  opinion  that  bad  nutrition  of 
the  mother  during  pregnancy,  or  poisoning  by  such 
agents  as  alcohol  and  morphia,  were  sometimes  to 
blame.  Sir  James  Crichton-Browne  referred  to  an 
idiot  he  had  seen,  whose  mother  during  pregnancy  had 
Asiatic  cholera.  Her  children  born  both  before  and 
after  this  were  healthy.  Dr.  Potts*  has  recorded  a 
single  case  of  mental  defect  in  the  middle  of  a  large 
family,  probably  due  to  the  mother  sustaining  a  com- 
plicated fracture  of  the  arm  during  pregnancy.  He 
ascertained,  however,  that  the  mother  was  a  con- 
firmed alcoholic,  and  expressed  the  opinion  that  such 

*  "  Causation  of  Mental  Defect  in  Children/'  Brit.  Medt 
Journal,  October  14,  1905. 


loo        MENTALLY  DEFICIENT  CHILDREN 


unfortunate  developments  only  occurred  when  some 
other  factor  was  also  present.     Such  was  the  case  in 
an  instance  he  recorded  of  feeble-mindedness  ascribed 
by  the  parents  to  the  father  having  a  severe  attack  of 
smallpox  some  twelve  months  before  the  child  was 
born.     There  is  reason  to  think  that  severe  attacks 
of  malaria  and  other  infectious  fevers  shortly  before 
conception  may  have  serious  effects  on  the  mental 
capacity  of  the  child.     While  dealing  with  this  aspect 
of  the  subject,  we  may  refer  to  the  possible  conse- 
quences of  artificial  restriction  of  families,  and  also 
of  attempts  to  procure  abortion.     Sir  James  Crichton- 
Browne,  in  his  evidence  to  the  Royal  Commission, 
said:   "One  cause  productive  of  idiocy  or  feeble- 
mindedness  operating   during   utero-gestation,    and 
deserving  of  careful  attention  at  this  time,  is  attempts 
to  procure  abortion.     When  that  is  instrumentally 
attempted  without  success,  injury  may  be  done  to 
the  head  of  the  foetus,  and  when  drugs  are  used  these 
may   disastrously  interfere  with   its  nutrition   and 
growth.  .  .  .     These  attempts  at  abortion,  and  also 
the  practices  employed  to  prevent  pregnancy,  with 
a  view  to  the  restriction  of  the  family,  are  said  by 
all  the  physicians  who  gave  evidence  before  the  New 
South  Wales    Commission    to    have    a  detrimental 
effect  on  the  nervous  system  of  the  woman,  pro- 
ducing hysteria,  neurasthenia,  and  mental  disturb- 
ance, and  thus  acting  unfavourably  on  the  health  of 
any  children  who  may  be  subsequently  born."* 

Mentally  feeble  children  are  often  the  offspring 
of  highly  neurotic  parents,  sometimes  of  highly  cul- 
tured persons  exceptionally  gifted  in  a  particular 
direction.  It  would  seem,  indeed,  in  some  cases  that 

*  Report  of  the  Royal  Commission  on  the  Feeble-Minded, 
1908,  vol.  i.,  p«  330. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      101 

the  parents  have  themselves  expended  so  much  of 
their  nervous  energy  that  they  have  little  left  to  trans- 
mit to  their  offspring;  familiar  instances  will  occur  to 
everyone  of  distinguished  men  and  women  afflicted 
with  children  whose  mental  endowments  are  below 
the  average.  Bearing  in  mind  the  aphorism  that 

"  Great  wits  are  sure  to  madness  near  allied," 

and  that  a  neurotic  temperament  is  sometimes 
associated  with  intellectual  brilliancy,  this  need  not 
surprise  us,  though  parents  usually  consider  it  as 
extraordinary.  Mental  feebleness  is  in  some  cases 
merely  a  consequence  of  feeble  health ;  with  improved 
physical  conditions  the  mental  impairment  may 
gradually  disappear. 

Among  CAUSES  ACTING  AT  BIRTH,  that  to  which 
most  importance  attaches  is  prolonged  parturition. 
It  has  been  alleged  by  Drs.  Winkler,  Bollaan,  and 
others,  that  the  use  of  forceps  is  accountable  for  a 
considerable  amount  of  cerebral  injury  and  conse- 
quent mental  impairment.  So  far  from  this  being 
the  case,  it  appears  from  Shuttleworth's  and  Fletcher 
Beach's  statistics  that  protracted  pressure  without 
instrumental  interference  is  a  more  potent  cause  both 
of  mental  and  nervous  defect,  the  latter  factor 
figuring  more  than  four  times  as  often  as  the  former 
(i.e.,  14-24  per  cent.,  as  compared  with  3-31)  in  their 
combined  etiological  table,  whilst  in  addition  the 
occurrence  of  asphyxia  neonatorum  is  noted  in  12-96 
per  cent,  of  Dr.  Beach's  cases.  The  late  Dr.Langdon- 
Down,*  indeed,  estimated  the  frequency  of  the  latter 
condition  at  20  per  cent,  amongst  imbecile  children 
generally,  and  at  40  per  cent,  amongst  those  who 

*  "  The  Obstetric  Aspects  of  Idiocy/'  Trans.  Obstet.  Society, 
1876. 


loa      MENTALLY  DEFICIENT  CHILDREN 

were  first-born.  It  is  unquestionable  that  the 
asphyxia  neonatorum  so  often  due  to  protracted  un- 
assisted labours  is  in  some  cases  followed  by  paralysis, 
and  enfeeblement  more  or  less  severe  of  the  intellec- 
tual powers.  It  probably  accounts  for  some  of  the 
milder  types  of  mental  feebleness,  although  some- 
times the  asphyxia  is  the  first  indication  of  mental 
and  physical  weakness. 

Premature  birth  was  noticed  as  a  factor  in  3-52  per 
cent,  of  the  cases  recorded  by  Dr.  Shuttle  worth. 
Although  insufficient  in  itself  to  determine  mental 
defect,  this  accident  may  just  turn  the  scale  when 
there  are  other  predisposing  influences. 

CAUSES  WHICH  COME  INTO  PLAY  AFTER  BIRTH  are 
commonly  heard  of,  as  parents  readily  put  these 
forward  rather  than  the  praenatal  cause  of  a  con- 
genital defect,  which  they  are  loth  to  recognise, 
Coasequently  such  assigned  causes  as  a  fall,  a  fit, 
or  a  fright,  must  be  received  with  caution,  and  it 
must  be  borne  in  mind  that  such  may  be  at  most  the 
exciting  cause,  sometimes  merely  the  consequence  or 
coincidence,  of  a  nervous  catastrophe  to  which  the 
child  is  congenitally  predisposed.  In  the  last  chapter 
we  referred  to  the  pathology  of  developmental  cases, 
and  under  this  head  many  of  those  produced  by 
causes  acting  after  birth  would  properly  fall.  This 
remark  applies  especially  to  the  cause  most  com- 
monly assigned  of  all  others  for  mental  deficiency 
in  children — -viz.,  Convulsions  during  teething 
(eclampsia) — which  figured  in  the  statistics  of  the 
Royal  Albert  Asylum  to  the  extent  of  32-58  per 
cent,  (nearly  one-third  of  the  admissions).  There 
is  no  doubt  that  infantile  convulsions  frequently 
occur  without  producing  any  subsequent  mental  im- 
pairment ;  when  it  follows  it  is  safe  to  assume,  except 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      103 


when  inflammatory  lesions  have  been  set  up,  that 
there  has  been  some  inherited  brain  abnormality. 
Epilepsy  is  also  a  commonly  assigned  cause.  Accord- 
ing to  Dr.  Tredgold,*  a  special  examination  with 
regard  to  convulsions  in  over  500  mentally  defective 
patients  showed  that  in  cases  presenting  no  paralysis 
or  other  indication  of  gross  cerebral  lesions,  and  in 
whom,  therefore,  the  attacks  were  idiopathic  epilepsy, 
convulsions  occurred  in  37  per  cent. ;  whilst  in  patients 
presenting  signs  of  gross  lesions  they  occurred  in 
70  per  cent.  There  are  cases  in  which  a  previously 
bright  child,  afflicted  with  epilepsy,  falls  into  a  state 
of  mental  hebetude;  but  in  the  majority  of  cases  both 
the  epilepsy  and  the  mental  abnormality  are  con- 
sequences of  inherited  nervous  instability.  Though 
slight  injuries  are  often  set  forth  as  causes  when  quite 
inadequate,  Traumatism  (chiefly  in  the  form  of  injury 
to  the  head)  is  a  bond-fide  cause  in  a  number  of  cases — • 
e.g.,  in  8-25  per  cent,  of  the  admissions  to  the  Royal 
Albert  Asylum.  Fright  or  shock  (mental)  showed  as 
a  factor  in  about  3  per  cent,  of  the  cases ;  and  in  such 
instances  as  that  of  a  child  cruelly  locked  up  in  a  dark 
cupboard  for  several  hours,  or  scared  and  bitten  by  a 
fierce  dog,  these  shocks  may  be  contributing  causes. 
Severe  febrile  illnesses,  such  as  whooping-cough,  scar- 
latina, measles,  and  smallpox,  were  assigned  as  causes 
in  nearly  10  per  cent,  of  the  admissions  to  the  Royal 
Albert  Asylum,  and,  where  meningitis  had  supervened, 
probably  with  truth.  It  is  remarkable  that  the 
statistics,  both  at  Lancaster  and  Darenth,  gathered 
at  a  time  when  the  worst  features  of  our  elemen- 
tary school  system  were  in  vogue,  give  but  little 
prominence  to  "•  over-pressure  as  a  factor,  being 
noted  in  only  0-16  per  cent,  of  the  2,380  cases, 
*  Mental  Deficiency,  1914,  p.  22 T. 


io4      MENTALLY  DEFICIENT  CHILDREN 

DIAGNOSIS. — The  practical  question  often  arises: 
How  shall  we  recognise  mental  abnormality  in  a  young 
infant  ?  And  the  further  inquiry  may  follow — Is 
the  mental  abnormality  primary  or  secondary? 
Mothers  are  proverbially  blind  to  imperfections  in 
their  offspring,  and  in  many  cases  it  falls  to  the 
medical  attendant  to  point  out  the  painful  fact  that 
the  poor  baby  is  not  "  all  there."  It  behoves  him, 
therefore,  to  be  well  posted  in  the  diagnostic  marks  of 
infantile  feeble-mindedness. 

As  regards  the  question  of  the  earliest  age  at  which 
mental  deficiency  can  be  recognised,  we  may  say  that 
in  well-marked  cases  a  diagnosis  is  possible  during 
the  early  months  of  life.  If  there  is  great  difficulty  in 
getting  the  baby  to  suck,  and  careful  examination 
shows  no  physical  condition  in  either  mother  or  child 
to  account  for  this,  mental  weakness  may  be  sus- 
pected. It  would  be  confirmed  by  the  child's  con- 
figuration conforming  to  one  of  the  definite  types 
described  in  the  last  chapter,  such  as  the  Micro - 
cephalic  or  Mongolian.  Discrimination  must  be 
exercised  in  deciding  that  there  is  an  approximation 
to  the  type  as  a  whole,  and  not  merely  an  exhibition 
of  one  of  its  more  prominent  features,  such  as  an 
epicanthic  fold,  which  is  not  very  uncommon  in 
normal  individuals.  On  the  other  hand,  we  cannot 
expect  to  find  the  transverse  furrows  on  the  tongue 
in  an  infant  mongolian,  for  they  develop  later. 
Cretins  have  been  diagnosed  at  the  third  month,  but 
when  no  definite  type  is  recognised,  judgment  must  be 
postponed  and  the  progress  of  development  carefully 
watched.  In  the  slighter  cases  sometimes  no  definite 
opinion  can  be  given  till  seven  years  of  age,  or  even  a 
little  later. 


PLATE  XII. 


ANTKRO-FOSTERIOB  CIRCUMFERENCE. 


TRANSVERSE 


Fig.  ?. 


Fig.   3. 


COMPARATIVE  CRANIAL  CONTOURS. 


Fig.  i. — Microcephalic  Contours.  Fig.  2. — "Mongolian"  Contours. 

Fig.  3.  — Hydrocephalic  Contours. 


To  face  page  105* 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      105 

The  DIAGNOSTIC  marks  of  infantile  mental  defect 
may  be  grouped  under  four  heads — -viz. : 

1.  Cranial  Abnormalities. 

2.  Formative  and  Developmental  Defects. 

3.  Abnormality  of  Nervous  Action. 

4.  Defects  in  Nutrition. 

i.  Cranial  Abnormalities. — The  most  significant  is, 
of  course,  Microcephalus.  As  previously  stated,  not 
only  deficient  size,  but  also  a  characteristic  form  of 


FIG-    2. MlCROCEPHALIC    IDIOT,    AGED    2O. 

(From  Journal  of  Psycho- Asthenias.) 

head,  is  indicative  of  this  abnormality  (see  p.  59,  ante). 
Taking  the  average  head  circumference  at  nine 
months  as  17  inches,  and  at  twelve  months  as 
18  inches,  any  notable  deficiency  in  head  measure- 
ment in  a  child  otherwise  of  normal  size  may  be  taken 
to  suggest  microcephalus.  The  typical  form,  which 
confirms  the  diagnosis,  comprises  a  narrow,  rapidly 
receding  forehead,  a  flat  occiput,  and  a  pointed  vertex, 
thus  exhibiting  two  marked  angles,  at  the  centre  of 


106      MENTALLY  DEFICIENT  CHILDREN 

the  face  and  the  top  of  the  head.  We  have  seen 
typical  microcephalic  adults  whose  head  circumfer- 
ence exceeded  20  inches,  and  Dr.  Tredgold*  refers  to 
one  whose  measurement  was  21  inches.  The  palate 
is  high  and  narrow ;  in  form,  like  a  V  or  a  Gothic  arch. 
Such  abnormality  of  palate,  though  more  frequent  in 
mentally  defective  children,  is,  however,  by  no  means 
a  definite  indication  in  these  days  of  teats  and  feeding- 
bottles. 

Intra-uterine  Hydrocephalus  generally  gives  rise  to 
a  difficult  labour,  and  the  cranial  abnormality  in  the 
child  is  not  likely  to  escape  notice.  The  head  is 
globular,  and  the  greatest  enlargement  is  in  the  cir- 
cumference at  the  level  of  the  temples,  giving  the 
typical  top-heavy  appearance;  there  is  some  bulging 
at  the  fontanelles  and  along  the  sutures.  Though 
the  diagnosis  is  usually  self-evident,  there  are  cases 
without  marked  enlargement  of  the  head;  in  such 
cases  the  diagnosis  is  based  on  periodic  attacks  of 
headache  and  vomiting  associated  with  physical  signs 
dependent  on  an  increase  of  pressure. 

Hypertrophic  cases,  although  less  striking,  attract 
attention  in  much  the  same  way.  A  diagnosis  from 
Hydrocephalus  can  be  made  by  noticing  that  the 
skull  looks  square  rather  than  round,  and  that  the 
increase  in  size  is  most  marked  just  above  the  super- 
ciliary ridges  instead  of  at  the  temples,  while  there  is 
no  bulging  of  the  fontanelles  or  sutures.  The  enlarge- 
ment is  more  even  and  general  than  in  rickets,  which 
is  the  commonest  cause  of  a  large  head;  in  doubtful 
cases  careful  examination  of  other  parts  of  the  body 
should  establish  a  diagnosis,  and  prevent  any  con- 
fusion with  cretinism,  achondroplasia,  cleido-cranial 
dysostosis,  or  congenital  syphilis.  Bossy  enlarge- 
*  A.  F.  Tredgold,  Mental  Deficiency,  1914,  p.  207, 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      107 


ments  of  the  skull  are  characteristic  of  the  two  latter, 
but  are  also  found  in  rickets,  which  may  be  associated 
with  hypertrophic  cases.  In  hypertrophy  the  circum- 
ference is  less  than  in  hydrocephaly,  there  being  no 
record  of  one  over  25  inches.  For  purposes  of  com- 
parison, it  is  useful  to  remember  that  the  average 
circumference  of  the  normal  head  at  five  years  of 
age  is  20  to  2O-J-  inches,  and  at  ten  21  inches,  while 
in  the  female  adult  it  is  21 J  inches,  and  in  the  male 
adult  22  inches. 

Oxycephaly,  with  its  great  increase  in  the  vertical 
measurement  of  the  cranium,  and  the  shallow  furrows 
above  the  temples,  can  scarcely  be  mistaken,  nor  can 
Scaphocephaly.  The  configuration  of  the  head  in 
both  these  conditions  has  been  fully  described  in  the 
last  chapter  (see  pp.  63,  73  and  74,  also  Plates  VII. 
and  X.,  and  Fig.  3,  p.  108). 

The  so-called  "  Mongol  "  type  leaves  its  impress  not 
only  on  the  physiognomy,  but  on  the  form  of  the  head, 
as  has  already  been  described;  and  there  should  be 
no  difficulty  in  recognising  it  even  in  early  life.  The 
brachycephalic  skull,  and  the  "  almond-shaped," 
obliquely  set  palpebral  fissures,  are  quite  character- 
istic; the  other  physical  features  will  be  described  a 
little  later,  and  also  the  differential  diagnosis  from 
Cretinism,  to  which  it  often  bears  a  superficial  re- 
semblance. 

Marked  asymmetry  of  the  skull  is  met  with  in 
HEMIPLEGIC  cases;  other  distortions  sometimes  occur, 
especially  after  a  difficult  labour.  Occasionally  in- 
juries from  forceps  leave  a  permanent  mark,  but 
in  our  experience  these  are  not  more  common  with 
defective  than  with  normal  children.  Asymmetry 
must  not  be  taken  as  of  itself  a  sign  of  mental  defect; 
indeed,  in  adult  life  it  is  said  to  be  a  mark  of  culture. 


io8      MENTALLY  DEFICIENT  CHILDREN 

Prolonged  (dolichocephalic)  crania  with  a  median 
longitudinal  ridge,  especially  over  the  sagittal  suture, 
are  met  with  both  in  normal  and  abnormal  children, 
and  consequently  the  scaphocephalic  form  cannot  be 
called  diagnostic.  But  the  persistence  of  a  medio- 
frontal  suture,  or  the  existence  of  a  medio-frontal 
ridge  towards  which  a  narrow  forehead  tapers,  may 
be  accepted  as  signs  of  imperfect  development  of  the 
frontal  lobes. 


FIG.  3. — ANTERO-POSTERIOR  AND  CIRCUMFERENTIAL 
CONTOURS  OF  SCAPHOCEPHALIC  CRANIUM. 

In  cases  where  there  is  any  possibility  of  an  injury 
at  birth  or  later,  the  X  rays  may  give  much  assistance 
in  the  diagnosis.  For  instance,  in  a  case  seen  recently 
by  Dr.  Shuttleworth,  a  skiagram  showed  thinning  of 
the  bone  near  vertex,  with  a  shadow  below,  probably 
due  to  an  organised  clot.*  There  had  been  a  definite 
injury  at  birth. 

2.  Formative  and  Developmental  Defects. — As  signs 
of  imperfection  of  physical  development  are  often  as- 
sociated with  mental  defect,  we  should  look  for  such 
abnormalities  of  formation  as  hare-lip;  delayed  or 
irregular  dentition;  cleft,  high, and  misshapen  palates; 

*  See  Plates  XIII.  and  XIII (A). 


PLATE  XIII.- 


1 1  mEm  m  I 


DEDUCED    FROM    SKIAGRAM    (BY    DR.    N.    S.    FlNZl)    OF    CHILD    THREE    YEARS 
OLD    SUFFERING    FROM    EPILEPSY.       ANTERIOR    VlEW   OF    HEAD. 

(Arrow  indicates  irregularity  of  cranial  contour.) 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      109 

small,  rudimentary,  or  misshapen  auricles,  sometimes 
set  too  far  back,  or  at  different  levels  on  the  two  sides, 
or  outstanding;  supernumerary  auricles  represented 
by  tags  of  projecting  skin;  epicanthic  folds  extending 
across  the  caruncle ;  opacity  of  ocular  media;  coloboma 
iridis ;  nose  unusually  indented  at  bridge  or  depressed ; 
nostrils  looking  forward,  or  shaved  off  at  the  sides; 
hairy  growths  or  moles  on  forehead  or  face;  naevi; 
rough  and  scaly  condition  of  skin;  imperfections  of 
nails;  general  blueness  of  face,  lips,  etc.,  from  cardiac 
malformation;  blueness  and  coldness  of  hands  and 
feet.  None  of  these  stigmata  of  physical  failure  neces- 
sarily imply  mental  deficiency,  but  their  occurrence 
will  lead,  especially  if  several  be  observed,  to  suspicion 
on  the  subject.* 

3.  Abnormality  of  Nervous  Action. — Spontaneous 
muscular  activity,  though  with  movements  minute 
in  character  (the  "  microkinesis  "  of  Dr.  F.  Warner), 
incessant  during  waking  hours,  is  the  characteristic 
of  healthy  infant  life.  If  these  movements  be  absent 
or  excessive,  we  may  reasonably  suspect  something 
wrong  with  the  nervous  system,  and  predicate 
mental  irregularities.  In  the  former  case  we  shall 
find  a  dull,  vacant  expression,  sometimes  associated 
with  imperfect  reflexes,  so  that  even  the  function  of 
sucking  is  not  properly  accomplished.  In  the  latter 
there  is  over-mobility,  perhaps  nystagmus,  and 
twitching  movements  of  the  muscles  of  the  face.  A 
general  tremor  is  also  sometimes  met  with.  As 
indications  of  mental  deficiency,  we  must,  of  course, 
be  guided  by  the  extent  of  the  departure  from  the 
normal  in  one  direction  or  the  other.  As  the  age 
of  the  child  increases,  we  must  carefully  watch  the 
evolution  of  its  senses,  and  note  deficiencies  of  touch, 


See  Plate  I.,  facing  p.  12. 


no     MENTALLY  DEFICIENT  CHILDREN 

sight,  hearing,  etc.  At  a  later  stage,  the  absence  of 
attempts  at  speech,  when  the  hearing  is  not  affected, 
will  be  of  much  value  as  a  diagnostic  sign.  So  also 
will  be  lack  of  muscular  co-ordination  and  consequent 
inability  to  walk,  independent  of  paralytic  affection. 
4.  Defects  in  Nutrition. — The  emaciated,  wizened 
features  of  the  slum  baby,  so  often  seen  in  the 
children's  wards  of  East-End  hospitals,  furnish  an 
extreme  example  of  these  defects.  These  may  arise 
from  injudicious  feeding;  but  there  is  undoubtedly 
a  congenital  state  of  malnutrition,  evidenced,  for 
instance,  in  cases  of  inherited  syphilis.  Persistent 
defects  of  nutrition,  in  spite  of  good  feeding,  are 
symptomatic  of  defect  of  original  constitution,  and 
are  not  infrequently  associated  with  mental  deficiency. 
This  fact  was  remarked  by  Dr.  Warner  in  his  inspec- 
tion of  Poor  Law  Schools,  where,  notwithstanding 
good  feeding,  the  tendency  to  low  nutrition  was  in 
greater  ratio  than  with  ordinary  school  children. 
•  To  sum  up,  we  shall  find  aid  in  diagnosing  the 
PRIMARY  character  of  mental  deficiency  by  noting 
abnormalities  in  the  form  and  shape  of  head,  and  the 
condition  of  the  cranial  sutures;  by  looking  for  the 
physical  stigmata,  if  not  of  degeneration,  at  any  rate 
of  arrested  development;  and  by  seeing  signs  of 
abnormal  nervous  action  and  a  constitutional  ten- 
dency to  imperfect  nutrition.  The  occurrence  of 
asphyxia  neonatorum,  the  absence  of  a  healthy  cry, 
defect  of  reflex  action  and  of  grasping  power,  im- 
perfect reaction  to  light  and  sound,  absence  or  excess 
of  spontaneous  movement,  and  (as  time  goes  on) 
inability  to  notice  objects  or  to  fix  the  attention, 
with  tardiness  of  attempts  at  speech  and  at  walking, 
are  some  of  the  symptoms  marking  the  child  as- 
different  from  other  children.  As  a  definite  guide  we 


&fiOLO'Gy.  DIAGNOSIS,  AND  PROGNOSIS      ni 


may  state  the  time  at  which  certain  functions  develop 
in  a  normal  child;  there  are,  however,  great  varia- 
tions even  in  healthy  children,  so  that  considerable 
latitude  must  be  allowed.  Touch,  taste,  and  probably 
smell,  are  more  or  less  developed  at  birth,  at  which 
time  the  infant  should  present  a  developed  voice, 
and  cry  vigorously.  The  power  of  hearing  is  soon 
established;  the  eyes  are  sensitive  to  light  from  the 
first,  but  there  is  a  lack  of  power  to  interpret  the 
images  received.  By  the  fifth  or  sixth  week  ob- 
jects are  followed  by  the  eye,  and  at  the  same  time 
the  child,  whose  features  have  previously  been  more 
or  less  passive,  begins  to  smile.  From  two  to  three 
months  is  the  time  at  which  it  can  sustain  its  head 
without  assistance,  but  this  is  done  in  a  vacillating 
way  till  the  fourth  or  fifth  month.  By  the  sixth 
month  it  can  sit  up  with  ease,  and  accomplish  many 
movements  with  its  arms,  hands,  and  fingers,  and 
enjoy  playthings.  Between  the  seventh  and  ninth 
months  it  may  be  put  on  the  floor  alone,  and  can 
amuse  itself.  When  from  ten  to  twelve  months  old, 
it  begins  to  crawl,  and  is  generally  able  to  walk  at 
some  time  between  the  twelfth  and  sixteenth  months. 
When  twelve  months  old,  the  child  begins  to  enunciate 
single  words,  and  when  eighteen  months  or  two  years 
learns  to  form  short  sentences. 

In  SECONDARY  AMENTIA  there  is  a  history  of 
normal  development  till  the  occurrence  of  a  definite 
injury  or  disease  followed  by  deterioration. 

Tests  of  Intelligence. — Having  explained  the  dia- 
gnosis as  far  as  it  can  be  based  on  anatomical  and 
physical  grounds,  or  abnormality  of  nervous  action, 
it  will  be  useful  to  indicate  how  the  intelligence  may 
be  tested  both  in  older  children  and  adults.  In  the 
first  place,  the  personal  history  and  information  as  to 


ii2    MENTALLY  DEFICIENT  CHILDREN 

habits  and  conduct  must  be  obtained  from  parents  or 
others  in  charge  of  the  patient,  knowledge  as  to 
which  is,  indeed,  essential  before  certificates  can  be 
made  out  under  the  Mental  Deficiency  Act.*  No 
better  illustrations  of  the  kind  of  facts  required  can 
be  given  than  by  quoting  extracts  from  the  "  Facts 
communicated  by  Others  "  in  the  medical  certificates 
of  cases  already  dealt  with  under  the  Act.  Among 
others  we  have  the/  following  statements:  "  Has 
always  been  dull  and  backward,"  "  Has  never  been 
like  other  children,"  "  Has  never  grown  up/'  "  Can 
do  no  useful  work,"  "  Never  works  except  under 
supervision,"  "  Loses  his  way,"  "  Cannot  take  care 
of  himself,"  "  Cannot  go  any  errands,"  "  Cannot  be 
trusted  with  money,"  "  Has  never  been  able  to  earn 
anything,"  "  Cannot  keep  a  situation,"  "  Abnormally 
passionate,"  "  Extraordinarily  obstinate,"  "  Open  to 
any  suggestion,"  "  Will  never  wash  himself,"  "  Has 
no  memory."  The  Birmingham  After-Care  (Special 
Schools)  Committee  found  that,  among  the  high- 
grade  feeble-minded  who  were  able  to  get  work  after 
leaving  school,  mental  defect  often  made  itself  plain 
by  a  constant  change  of  situation  (seven  or  eight  in 
a  year),  and  inability  to  ever  earn  a  living  wage. 

As  regards  the  observations  at  the  time,  it  may  be 
said  that  there  is  no  examination  and  no  set  of  tests 
which  provide  an  absolute  standard;  the  opinion  of 
an  expert  after  a  few  minutes'  conversation  is  of 
much  greater  value  than  the  records  of  a  series  of 
tests  conducted  by  a  tyro,  who  judges  by  their  result 
only.  Sometimes  numerous  scars  of  cuts  and  burns 
will  be  seen,  suggestive  of  the  patient's  inability  to 
take  care  of  himself.  In  others  the  slovenly  dress 
and  torn  clothes  give  a  useful  clue.  The  manner  of 

*  Form  of  certificate  will  be  found  in  Appendix  E.  p.  264. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      113 

the  patient  is  of  the  utmost  importance.  How  does 
he  enter  the  room  ?  How  does  he  meet  a  stranger  ? 
Gait  and  carriage  must  be  carefully  observed.  How 
does  he  conduct  himself  during  the  examination  ? 
Does  he  take  an  intelligent  interest,  or  is  he  quite  in- 
different ?  What  is  his  capacity  for  attention  and 
concentration  ?  If  he  cannot  read  or  write,  or  tell 
the  time,  or  perform  simple  calculations,  in  spite  of 
training,  the  diagnosis  is  usually  clear.  If  he  has 
such  elementary  knowledge,  he  may  still  fail  in  very 
simple  tests.  Of  course,  in  all  of  these  allowance 
must  be  made  for  age,  and  also  for  any  lack  of  educa- 
tion. Here,  again,  we  can  give  our  readers  no  more 
practical  assistance  than  by  quoting  from  actual 
certificates  for  detention.  "  Does  not  know  the 
date/'  "  Does  not  know  when  Christmas  Day  is," 
"  Does  not  know  when  his  birthday  is,"  "  Does  not 
know  how  long  he  has  been  in  this  institution/' 
"  Told  me  that  a  penny  was  a  halfpenny,  and  a  shil- 
ling a  threepenny  bit/'  "  Says  a  horse  has  two  legs," 
"  Does  not  know  which  is  his  right  hand,"  "  Told  me 
that  a  horse  has  feathers  on  its  head,"  "  Does  not  see 
any  necessity  for  earning  his  own  living,"  "  Does  not 
know  how  many  brothers  he  has,"  "  Cannot  say  what 
he  had  for  dinner,"  "  Cannot  describe  how  he  came 
here,"  "  Says  the  word  insensible  means '  Are  you  sens- 
ible ? ' '  ' '  Says  the  opposite  of  ugly  is '  Are  you  ugly  ? ' ' 
Special  tests,  sometimes  useful,  are  on  the  follow- 
ing lines: 

1.  Turn  patient's  coat-sleeves  inside  out,  and  tell 
him  to  put  it  on. 

2.  Give  him  a  knotted  cord  to  untie. 

3.  Give  him  a  match  to  strike. 

4.  Saying  which  feature  is  missing  in  an  imperfectly 
drawn  human  figure. 


H4      MENTALLY  DEFICIENT  CHILDREN 


5.  Crossing-out  test  (letters  or  groups  of  different 
numbers  of  dots). 

6.  Distinguishing  the  ugly  from  the  beautiful  in 
pairs  of  face  illustrations. 

7.  Tell  him  to  repeat  as  many  words  (names  of 
objects,  etc.)  as  he  can  in  three  minutes  (a  child  of 
eleven  should   be   able  to  give    at   least  sixty;  an 
adult  ought  to  give  nearly  sixty  per  minute) . 

The  most  important  point  often  is,  not  whether 
the  correct  solution  is  obtained,  but  how  the  prob- 
lem is  approached  and  carried  out.  The  interpreta- 
tion of  pictures  is  a  valuable  form  of  test. 

SECONDARY  cases  are  differentiated  by  the  absence 
of  signs  of  original  defect:  by  a  history  of  a  normal 
condition  in  infancy  until  the  occurrence  of  some 
serious  accident,  illness,  or  shock,  which  was  fol- 
lowed by  mental  enfeeblement.  Caution  is  necessary 
in  accepting  the  statements  of  parents  on  these 
matters,  and  it  must  be  remembered  that  a  certain 
number  of  cases,  not  obviously  suffering  from  con- 
genital defect,  are  born  with  brains  so  unstable  as 
to  be  unable  to  withstand  the  stress  of  life,  and  these 
may  break  down  at  a  crisis  of  child  development,  or 
after  a  comparatively  slight  injury  which  would 
leave  a  normal  child  unharmed. 

Before  discussing  any  special  types,  a  few  general 
remarks  on  PROGNOSIS  will  be  useful.  This  is  an 
aspect  of  the  subject  to  which  parents  and  guardians 
not  unnaturally  attach  the  greatest  importance. 
First  we  may  remark,  with  regard  to  the  broad 
division  into  primary  and  secondary  cases,  that  the 
prognosis  in  the  former  is,  as  a  rule — contrary  to  the 
popular  idea  on  the  subject — better  than  in  the 
latter.  The  fact  is  that  in  the  one  there  is  merely 
defective  development,  and  this,  under  favourable 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      115 


circumstances,  may  be  fostered  and  promoted;  in 
the  other  there  is  actual  lesion  of  brain  tissue,  more 
or  less  irremediable.  Superficial  appearances  are  in 
favour  of  secondary  cases,  for  the  others  are  often 
handicapped  by  ill-formed  and  sometimes  repulsive 
features;  yet  our  experience  is  quite  in  accord  with 
that  of  the  late  J.  Langdon-Down,*  that  "  the  prog- 
nosis is,  contrary  to  what  is  so  often  thought,  in- 
versely as  the  child  is  comely,  fair  to  look  upon,  and 
winsome."  There  are,  however,  a  few  cases  of  mild 
traumatism,  and  even  of  post-inflammatory  lesion, 
in  which  a  more  cheerful  view  may  be  taken,  especi- 
ally in  these  days  of  brilliant  brain  surgery. 

In  primary  cases  Dr.  Lapage  has  shown  that  the 
greater  the  mental  deficiency  the  later  is  the  child 
in  learning  to  walk  and  talk,  as  a  rule.  The  age, 
therefore,  at  which  these  accomplishments  were 
acquired  are  facts  of  considerable  importance  in 
prognosis.  A  comparison  with  the  facts  of  the 
development  of  infants  we  have  just  given  (p.  in) 
will  often  be  useful. 

In  the  first  instance  the  PROGNOSIS  must  be  guarded ; 
as  shown  in  our  concluding  chapter,  the  number  of 
defectives  who  are  capable  of  holding  their  own  in 
the  world  is  limited,  while  the  number  who  find  their 
way  into  institutions  is  large.  When  working  at 
Stoke-upon-Trent  for  the  Royal  Commission  on  the 
Care  and  Control  of  the  Feeble-minded,  Dr.  Potts 
showed  that  the  highest  grade  of  the  feeble-minded 
can  sometimes  work,  and  keep  themselves  for  a  time, 
yet  drift  into  the  workhouse  at  an  early  age.  Half 
of  all  the  cases  were  in  the  workhouse  by  the  time 
they  were  thirty.  Some  have  to  be  placed  in  lunatic 
asylums;  the  last  annual  report  of  the  Birmingham. 

*  Obstet.  Trans.,  vol.  xviii. 


n6       MENTALLY  DEFICIENT  CHILDREN 

After-Care  Committee,  published  in  June,  1915,  shows 
that  nearly  10  per  cent,  of  their  cases  have  met  with 
this  fate.  It  is  important  to  look  for  any  signs  of 
dementia  praecox,  which  affects  more  particularly 
the  higher  grades.  The  condition  often  develops 
soon  after  puberty;  first  will  be  noticed  failure  to 
improve;  later  peripheral  anaesthesia,  exaggerated 
tendon  reflexes,  and  signs  of  negativism  or  other 
disorder  of  action  characteristic  of  some  forms  of 
dementia  prsecox,  settle  the  case. 

Periodical  testing  by  the  Binet-Simon  scale  often 
helps;  the  child  who  improves  year  by  year  may 
achieve  something  after  leaving  school;  the  child 
who  fails  to  advance  after  eleven  or  twelve  never 
will.  Further  hints  on  prognosis  will  be  given  under 
the  special  types. 

Special  defects  such  as  word-deafness  and  word- 
blindness  are  not  recognised  till  the  child  is  of  school 
age ;  these  conditions  have  been  fully  discussed  in  the 
last  chapter,  and  only  require  to  be  mentioned  here. 

Passing  now  to  some  of  the  typical  groups,  let  us 
first  take  the  small  heads,  those  with  greater  or  less 
degree  of  Microeephalus.  The  theories  that  this  is 
an  atavistic  variation  or  the  result  of  premature 
synostosis  have  both  been  disproved ;  the  small  skull 
is  simply  the  envelope  of  the  brain  of  which  the 
normal  development  has  been  arrested,  probably 
about  the  fifth  month  of  gestation.  "  Microcephalies 
usually  come  of  a  pronounced  neuropathic  stock,  their 
brothers  and  sisters  are  often  typical  degenerates,  and 
frequently  one  or  more  of  them  suffer  from  the  same 
condition/'*  The  diagnosis,  as  has  been  explained 
in  the  last  chapter,  and  also  under  the  heading  of 
Cranial  Abnormalities,  depends  not  only  on  diminu- 

*  A.  F.  Tredgold,  Mental  Deficiency,  p.  175. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      117 

tive  size,  but  also  on  a  characteristic  shape  of  the 
head.  The  prognosis  may  be  said  to  be,  generally 
speaking,  favourable  or  otherwise,  in  proportion  to 
the  size  of  the  head.  With  heads  under  18  inches  in 
circumference  the  manifestation  of  mental  power  is 
usually  so  small  as  to  come  under  the  category  of 
idiocy;  between  18  and  19  inches  the  cases  may  be 
designated  as  imbecile;  and  from  19  to  20  inches  is 
not  an  uncommon  measurement  in  cases  of  mere 
"  feeble-mindedness."  There  is  hope  of  improvement 
under  training,  especially  for  the  higher  grades  of  this 
type.  Dr.  Shuttleworth  had  under  training  for  four 
years  a  mentally  feeble  boy  whose  head  circum- 
ference increased  during  that  time  from  19  to  2oJ 
inches.  As  the  sensorial  and  muscular  powers  are 
usually  good  in  microcephalic  cases,  the  powers  of 
sucking,  grasping,  etc.,  are  not  impaired,  while  the 
best  of  them  may  be  taught  industrial  work.  We 
have  known  a  girl  with  a  head  of  18  inches  employed 
as  an  assistant  dormitory  maid,  and  a  boy  with  a 
head  of  19  inches  helping  intelligently  in  a  bake- 
house. The  physical  health  of  microcephalic  children 
is  usually  not  amiss,  and  under  favourable  circum- 
stances they  may  live  to  adult,  and  even  advanced, 
years.  Some  simple  occupation,  not  requiring  head- 
work,  is  their  role,  the  mental  being  limited  by  the 
cranial  capacity. 

But,  as  old  Fuller  quaintly  puts  it,  though  "  heads 
are  sometimes  so  little  that  there  is  no  room  for  wit, 
they  are  sometimes  so  long  that  there  is  no  wit  for 
so  much  room/'  We  have  already  remarked  that 
long  heads  do  not  at  all  necessarily  go  with  mental 
deficiency — sometimes  the  reverse;  if  Fuller  had 
written  large  heads  instead  of  long,  it  would  have 
been  more  in  accord  with  our  experience.  We  refer, 


n8      MENTALLY  DEFICIENT  CHILDREN 


of  course,  to  the  Hydrocephalie  type.*  In  hydro- 
cephalus  the  degree  of  mental  defect  varies  greatly, 
and  is  not  proportionate  to  the  deformity.  The 
prognosis  is  usually  bad,  but  much  depends  on  the 
cause  and  age  at  which  it  occurs,  and  whether  the 
condition  is  stationary  or  slowly  progressive.  To 
determine  the  cause,  an  examination  of  the  fluid  with- 
drawn by  lumbar  puncture  may  be  useful;  this  is 
often  also  the  best  form  of  treatment.  The  distinc- 
tions previously  indicated  differentiate  this  type 
from  that  of  the  Hypertrophic  heads  occasionally 
met  with.  Hypertrophic  change  is  sometimes  asso- 
ciated with  rickets.  In  many  hypertrophic  cases 
there  is  considerable  muscular  weakness,  even  when 
the  bodily  health  is  fairly  good ;  manual  work  in  con- 
sequence is  done  with  difficulty,  and  the  speech  may 
also  be  affected.  There  is  often  complaint  of  headache ; 
sometimes  encephalitis  and  acute  mania  supervene. 
Epilepsy  is  often  a  complication;  sometimes  the  fits 
gradually  subside,  sometimes  they  get  steadily  worse, 
and  may  be  the  cause  of  death.  The  prognosis  of 
hypertrophy  of  brain  is  consequently  unfavourable, 
whereas  in  hydrocephalus,  after  the  acute  symptoms 
have  subsided,  the  prospects  of  improvement  under 
judicious  training  are  considerable. 

Cases  of  Oxycephaly,f  or,  as  it  is  better  called, 
"  Tower  skull,"  are  readily  recognised  by  the  large 
proptosed  eyes,  absence  of  supra-orbital  ridges,  and 
the  dome-shaped  mound  rising  up  from  the  forehead 
and  separated  from  the  temples  by  shallow  furrows. 
This  rare  condition  has  been  fully  described  in  the 
preceding  chapter  (p.  73). 

The  chief  characteristic  of  cases  Primarily  Neurotic 


*  See  Plate  V.  (opposite  p.  61). 
f   See  Plate  X.  (opposite  p.  73). 


PLATE  XIV. 


FIG.  i. — "  MONGOL  "  PROFILE. 


FIG.  2. — "  MONGOL  "  TONGUE. 
MONGOLIAN    TYPR 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      119 

is  the  impression  they  give  of  weakness,  mental  and 
physical;  there  is  little  power  of  attention.  Asked 
to  look  at  a  fixed  object  held  up  in  front  of  them,  the 
eyes  will  quickly  wander.  Children  of  this  typ'j 
are  slackness  personified.  If  told  to  extend  the  arms 
in  front,  their  response  is  feeble;  the  arms  are  not 
straight  nor  raised  to  the  shoulder-level.  Warner's 
"  weak  hand  balance  "  is  noticed.  c'  The  wrist 
droops,  the  bones  of  the  palm  of  the  hand  are  some- 
what folded  together,  while  the  thumb  drops  and  all 
the  fingers  are  slightly  bent."  Often  the  right  hand 
is  kept  at  a  lower  level  than  the  left.  The  "  prow- 
shaped  skull  "  sometimes  associated  with  this  con- 
dition has  been  fully  described  in  the  last  chapter. 
This  type  is  not  infrequently  blended  with  others. 
Cases  of  this  class  always  do  better  when  withdrawn 
from  home  influences,  which  are  prejudicial  (the 
common  neurotic  taint  of  parent  and  child  often 
interacting  injuriously).  Placed  under  judicious 
management  in  healthy  surroundings,  much  good 
may  be  done  by  suitable  drill  and  manual  exercises 
in  overcoming  the  twitchings  and  nervous  movements 
common  in  these  cases.  It  must  be  remembered 
that  such  individuals  are  weak  all  through,  and 
that  self-control  is  with  difficulty  established  and 
maintained.  There  is  a  special  danger  of  their  be- 
coming inebriate,  if  not  carefully  guarded.  Slight 
cases  of  this  group  are  not  uncommon,  and  are  often 
a  source  of  continual  anxiety  and  distress  to  their 
relatives  and  friends. 

With  regard  to  the  so-called  "  Mongol "  type,*  the 
form  of  the  head,  the  almond-shaped  eyes,  obliquely 
set,  the  epicanthic  folds,  and  the  squat  nose,  are 
quite  characteristic.  The  hands  are  usually  broad, 

*  See  Plates  XIV.,  XV.  (opposite  pp.  119,  120). 


120      MENTALLY  DEFICIENT  CHILDREN 

and  the  fingers  short,  the  little  finger  often  being 
curved  inwards.  The  feet  also  are  characteristically 
clumsy,  with  a  marked  cleft  between  the  big  and 
second  toes.  Laxity  of  the  joints  is  a  marked 
feature.  The  skin  is  usually  coarse  in  epidermis,  if 
\not  furfuraceous ;  many  have  sore  eyelids,  some 
fissured  lips;  the  hair  is  usually  wiry.  One  of  the 
most  striking  peculiarities  is  the  state  of  the  tongue, 
which  is  transversely  fissured  and  has  hypertrophied 
papillae.*  Dr.  John  Thomson^  states  that  in  the 
early  weeks  of  life  the  tongue  is  normal;  between  the 
third  and  ninth  months  the  papillae  get  enlarged, 
while  during  the  third  and  fourth  years  the  trans- 
verse fissures  appear.  This  latter  peculiarity  is 
possibly  due  to  tongue-sucking,  which  is  so  common 
in  this  type  of  defective,  acting  on  an  abnormally 
vulnerable  mucous  membrane. 

The  mental  condition  of  defectives  of  this  type  is 
almost  as  characteristic  as  the  physical ;  the  powers 
possessed  by  such  children  of  mimicry  are  often 
extraordinary;  their  love  of  music  great;  their  idea 
of  time  as  well  as  tune  remarkable,  so  that  they  are 
apt  at  drill  and  dancing.  In  some  ways,  therefore, 
they  are  full  of  promise,  but  they  seldom  accomplish 
much,  and  the  ultimate  outlook,  both  on  the  mental 
and  physical  sides,  is  unsatisfactory.  Something 
may,  however,  be  expected  from  a  favourable  en- 
vironment, and  cases  are  to  be  seen,  sheltered  in 
institutions,  of  mongolians  over  forty  years  of  age. 
In  adult  life  there  is  still  peculiarity  of  appearance, 
but  the  physical  characteristics  of  the  type  tend  to  be 
less  marked  as  age  advances.  Varied  gradations  are 

*  See  Plate  XIV.,  Fig.  2,  p.  119. 

f  John   Thomson,     "  Notes   on    the    Peculiarities    of    the 
in  Mongolism,"  Brit.  Med.  Journ.,  May  4,  1907. 


PLATE  XV. 


FIG.  i. 


FIG.  2. 
"  MONGOL  "  HANDS. 


To  face  page  120. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      121 

met  with,  from  the  mentally  feeble  child  with  the 
slight  "  mongol  "  taint,  to  the  idiot  whose  obliquely- 
set  almond-shaped  eyes  are  very  suggestive  of  the 
"  heathen  Chinee/'  Amongst  the  higher  grades  fairly 
satisfactory  results  of  mental  training  are  sometimes 
obtained.  Indeed,  we  know  youths  of  the  mildly 
"  mongol  "  type  who,  after  appropriate  education, 
pas's  muster  with  their  brothers  and  sisters.  Simple 
imitative  arts,  such  as  writing  and  drawing,  are 
acquired  without  much  difficulty,  but  the  coarsely 
convoluted  brain  is  unequal  to  higher  intellectual 
operations,  and  calculation  is  a  stumbling-block. 
Simple  industrial  occupation,  such  as  that  of  the 
garden  and  farm,  may  be  followed,  but  the  clumsy, 
ill-formed  fingers  militate  against  success  in  mechan- 
ical work  requiring  fine  adjustment.  From  the 
physical  side  the  prognosis  is  not  good.  They  are 
generally  delicate  and  very  susceptible  to  cold,  being 
apt  to  suffer  much  from  chilblains.  They  are  prone, 
moreover,  to  mucous  catarrhs  of  the  digestive  and 
respiratory  tracts,  and  the  majority  die  of  phthisis 
before  arriving  at  maturity.  Many  of  these  cases 
suffer  from  cataract,  probably  of  a  progressive  nature, 
for  it  is  not  observed  before  nine  years  of  age.  Dr. 
A.  W.  Ormond*  found  opacities  of  the  lens  in  nine- 
teen of  a  series  of  twenty-eight  cases.  They  are 
liable  also  to  congenital  heart  disease,  and  some  die 
young  from  this  cause.  On  post-mortem  examina- 
tion in  such  a  case,  the  foramen  ovale  is  usually 
patent,  and  there  may  be  in  addition  some  defect 
in  the  interventricular  septum,  as  described  by  Dr. 
Guthrie  in  the  discussion  on  Dr.  Archibald  Garrod's 
communication  to  the  Clinical  Society,  f  Cases  with 

*  A.  W.  Ormond,  Brit.  Med.  Journ.,  November  18,  1911. 
f  See  Brit.  Med.  Journ.,  October  22,  1898,  p.  1255. 


122      MENTALLY  DEFICIENT  CHILDREN 


this  defect  are  not  often  seen  in  institutions,  as  they 
usually  die  before  the  age  for  admission. 

We  have  suggested  in  the  past  that  they  are  essen- 
tially unfinished  children,  and  that  their  peculiar 
appearance  is  really  that  of  a  phase  of  foetal  life. 
Dr.  John  Thomson*  has,  however,  improved  upon 
our  description  by  the  use  of  the  term  "  ill-finished," 
pointing  out  that,  although  something  goes  wrong  in 
their  growth  in  very  early  intra-uterine  Hfe,  probably 
in  the  second  month,  yet  their  later  development 
goes  on  continuously,  though  badly.  Some  defect  of 
formative  force  may  usually  be  traced  in  connection 
with  the  intra-uterine  life  of  these  cases,  not  uncom- 
monly ill-health  or  mental  depression  of  the  mother; 
and  it  is  remarkable  that  nearly  half  of  these  children 
are  the  last  born  of  a  long  family,  when  the  procreative 
powers  are  at  a  low  ebb. 

Dr.  G.  A.  Sutherland!  nas  concluded  that  mon-v 
golism  is  probably  parasyphilis,  because  he-  found 
syphilis  in  eleven  of  his  series  of  twenty-five  cases, 
and  strongly  suspected  it  in  three  others.  We  have, 
however,  already  pointed  out  that  the  claim  that 
syphilis  is  responsible  for  a  large  percentage  of  cases 
of  mental  defect  is  far  from  established  as  yet.  Like 
Dr.  Tredgold,  {  we  have  seen  many  cases  of  mongolism 
in  which  syphilis  was  not  even  to  be  thought  of.  As 
evidence  in  favour  of  this,  we  can  state  that,  when 
Dr.  Gordon§  subjected  eight  cases  to  the  Wasser- 
mann  reaction,  not  one  gave  a  positive  result. 

*  John  Thomson,  in  Diseases  of  Children,  edited  by  Garrod, 
Batten,  and  Thursfield,  p.  882. 

f  G.  A.  Sutherland,  "  Mongolian  Imbecility  in  Infants," 
Practitioner,  December,  1899. 

J  A.  F.  Tredgold,  Mental  Deficiency,  second  edition,  p.  213. 

§  J.  L.  Gordon,  Lancet,  September  20,  1913. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      123 

We  have  already  pointed  out  that  mongolians  are 
not  instances  of  hereditary  mental  defect;  they  are 
frequently,  however,  found  in  families  with  a  neurotic 
taint. 

With  regard  to  Eclampsic  cases  (the  history  of 
which  will  help  us  to  a  diagnosis),  the  prognosis  varies 
with  the  severity  of  the  consequences  of  the  fits. 
A  certain  number  of  fits  of  doubtful  origin  in  infancy, 
even  when  they  recur  frequently,  leave  no  permanent 
bad  effect,  although  for  a  time  after  they  have  ceased 
the  child  is  dull  and  apathetic.  Nor  does  any  serious 
result  follow  the  so-called  "  rickety  fits/'  often  asso- 
ciated with  tetany  and  laryngismus  stridulus.  Still, 
the  prognosis  must  always  be  guarded,  as,  according 
to  Dr.  Leonard  Guthrie,  "  about  10  per  cent,  of 
infants  who  suffer  from  convulsions  become  epileptic 
in  after-life."* 

The  possibility  of  the  case  being  one  of  Tuberous 
Sclerosis  must  be  kept  in  mind ;  a  diagnosis  can  only 
be  made  when  there  is  a  palpable  renal  tumour  or 
peculiar  cells  in  the  urine,  or  the  condition  of  adenoma 
sebaceum  can  be  seen.  In  tuberous  sclerosis  the 
prognosis  is  always  bad,  death  taking  place  in  child- 
hood or  early  adult  life. 

As  regards  Epileptic  cases,  Dr.  W.  Aldren  Turnerf 
has  shown  that  mental  impairment  is  more  likely  to 
be  present  when  there  is  an  hereditary  neuropathic 
tendency.  His  records  from  the  Chalfont  St:  Peter 
colony  also  show  that,  while  some  epileptics  show  no 
mental  enfeeblement  after  thirty  years  or  more,  the 
majority,  as  time  goes  on,  develop  a  bad  memory  or 
more  serious  sign  of  failure,  29-1  per  cent,  becoming 

*  Diseases  of  Children,  edited  by  Garrod,  Batten,  and 
Thursfield,  1913,  p.  710. 

|   Epilepsy,  Aldren  Turner,  1907. 


I24      MENTALLY  DEFICIENT  CHILDREN 


actually  demented.  Where  epilepsy  is  associated 
with  the  lower  grades  of  idiocy,  the  probability  of 
organic  lesions  renders  the  prognosis  specially  un- 
promising. In  milder  cases  of  mental  enfeeblement 
associated  with  epilepsy,  the  successful  treatment 
of  the  epilepsy  is  followed  by  considerable  mental  im- 
provement, and  should  the  cessation  of  fits  be  per- 
manent, the  mental  deficiency  may  gradually  dis- 
appear. 

Epileptic  children  must  be  educated  according  to 
their  individual  mental  capacity.  Dr.  Shuttleworth 
found  that  of  the  470  epileptic  children  in  London 
submitted  to  him  by  the  educational  officers  for 
examination  and  report — 

(1)  17  per  cent,  were  cases  of  mild  epilepsy,  with 
no  obvious  mental  impairment,  and  were  suitable  to 
continue  in  the  ordinary  schools. 

(2)  27-5  per  cent,  showed  some  degree  of  mental 
impairment,  and  were  preferably  educated  in  special 
classes,  as,  owing  to  their  defective  memory  and  the 
lesser  degrees  of  mental  deficiency,  they  were  un- 
suited  to  compete  with  normal  children. 

(3)  40  per  cent,  were  capable  of  being  educated 
along  special  lines,  but,  owing  to  the  frequency  and 
severity  of  the  seizures,  additional  supervision  was 
necessary.     This  group  was  suitable  for  education 
in  residential  schools  or  colonies. 

(4)  15-5    per    cent,    were    epileptic    imbeciles    or 
dements,  and  were  incapable  of  education.     These 
required  care  in  an  idiot  asylum. 

According  to  Dr.  W.  A.  Turner,  a  "  cure  of  epilepsy 
may  be  defined  as  arrest  of  the  seizures  for  a  period 
of  eight  or  nine  years,  when  it  will  be  found  that  from 
10  to  12  per  cent,  of  cures  may  be  expected." 

Jn  the  last  chapter  we  have  described  the  important 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      125 

group  of  cases  associated  with  some  abnormality  of 
the  Sella  Turcica,  in  which  pituitary  extract  may  be 
given  with  beneficial  results. 

Syphilitic  cases*  can  be  distinguished  by  the  history 
and  signs  of  inherited  syphilis.  As  we  have  already 
pointed  out,  the  taint  is  undoubtedly  a  factor  in 
many  cases  of  mental  deficiency  where  its  external 
manifestations  are  not  obvious;  in  some  of  these 
careful  examination  of  the  rest  of  the  family  may 
give  an  important  clue,  while  the  Wassermann 
reaction,  as  explained  when  discussing  etiology,  is  a 
useful  but  not  infallible  guide.  Degenerative  changes 
due  to  this  cause  may,  indeed,  manifest  themselves 
early  in  life,  and  give  rise  to  cranial  osteitis,  meningeal 
inflammations,  and  eclampsic,  epileptic  and  paralytic 
symptoms,  so  often  associated  with  mental  defect  in 
children,  and  frequently  assigned  as  its  cause,  though 
more  correctly  to  be  regarded  as  links  in  the  chain  of 
causation.  While  discussing  cases  associated  with 
paralysis,  we  referred  to  the  important  work  both 
Dr.  Plaut  and  Dr.  Gordon  had  done  in  establishing 
the  close  relationship  of  syphilis  with  cases  of  mental 
defect  associated  with  motor  paralysis.  The  most 
characteristic  type  of  mental  degeneration  in  the 
young  associated  with  hereditary  syphilis  is  that 
designated  by  Dr.  Clouston  in  1877  "  juvenile  general 
paralysis  "  (or  by  Dr.  Judson  Bury  as  "  juvenile 
dementia "),  in  which  a  breakdown  (mental  and 
physical)  occurs  at  the  period  of  second  dentition 
or  advent  of  puberty,  leading  to  a  fatal  issue  in  a 
few  years.  The  first  sign  of  mental  weakness  is  the 
loss  of  the  most  recently  acquired  accomplishments — 
e.g.,  writing  or  arithmetic.  The  hesitating,  indistinct 

*  See  paper  by  G.  E.  Shuttleworth.  British  Journal  of  Chil- 
dren's Diseases,  April,  1908. 


126      MENTALLY  DEFICIENT  CHILDREN 


articulation  and  Argyll-Robertson  pupil  which  develop 
a  little  later,  together  with  the  general  feebleness  of 
the  limbs,  leave  no  doubt  as  to  the  diagnosis.  Such 
cases  are  found  not  to  be  so  rare  in  asylums  as  was 
formerly  thought,  and  Dr.  Mott  has  tabulated  the 
histories  of  twenty-two  in  volume  i.  of  the  Archives  of 
Neurology.  It  would  appear  from  this  table,  as  well 
as  from  a  paper  in  the  Practitioner,  January,  1908 
in  which  an  aggregate  of  forty  cases  are  dealt  with  by 
the  same  author,  that  in  at  least  80  per  cent,  of  these 
cases  there  was  evidence  either  of  a  syphilitic  family 
history  or  of  the  presence  of  syphilitic  stigmata  (in 
several  instances,  of  both),  .and  he  states  his  opinion 
that,  "  though  there  may  be  many  exciting  causes,  the 
predisposing  cause  of  this  disease  (juvenile  general 
paralysis)  is  nearly  always  hereditary  syphilis,"  thus 
agreeing  with  the  conclusions  of  Thiry,  Alzheimer, 
Mendel,  and  other  Continental  pathologists,  that 
inherited  syphilis  plays  a  predominant  role  in  its 
etiology. 

In  our  experience,  syphilitic  cases  do  not  respond 
much  to  education.  Even  if  they  survive  the  second 
dentition  and  puberty  without  changing  for  the  worse, 
they  do  not  as  a  rule  improve  in  any  way. 

In  cases  of  mental  deficiency  associated  with 
Paralysis,*  the  history  of  the  case,  and  the  occurrence 
of  convulsions  during  the  first  few  days  after  birth, 
distinguish  the  form  due  to  injury  at  birth  from  that 
associated  with  paralysis  developing  later  on  as  a 
result  of  some  toxic  condition  or  defective  vital  en- 
durance, or  a  vascular  lesion.  In  the  latter  there  is 
generally  a  history  of  convulsions  later  in  infancy, 
with  power  suddenly  lost  on  one  side;  when  the 
paralysis  begins  to  improve,  spastic  contractures  are 

*  See  Plate  IX.  (opposite  p.  72). 


WOOD-CARVING,  DESIGNED  AND  EXECUTED  BY  J.  B., 
ROYAL  ALBERT  ASYLUM. 

To  fa.cc  6a°e  l*7« 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      127 

left,  and  there  is  the  characteristic  hemiplegic  gait. 
In  the  first  class  of  cases,,  which  used  to  be  spoken  of 
as  birth-palsy,  the  mental  deficiency  is  often  more 
apparent  than  real,  and  the  patients  improve  wonder- 
fully under  appropriate  training.  The  paralysis  may 
be  either  hemiplegic  or  diplegic,  the  latter  being  the 
more  common ;  the  amentia  is  less  in  the  former  than 
in  the  latter.  The  athetotic  movements  sometimes 
disqualifying  them  from  ordinary  use  of  the  hands 
may  be  overcome  by  suitable  finger  exercises  (such 
as  will  be  hereafter  described) ;  as  considerable  power 
of  will  exists,  the  patient  will  often  be  able  to  co- 
operate with  the  doctor  in  trying  to  combat  his 
infirmities.  We  have  repeatedly  seen  children  of 
this  type,  at  first  unable  to  hold  a  pencil,  develop 
into  admirable  draughtsmen;  indeed,  the  graphic 
faculty  frequently  seems  to  be  good  in  these  cases. 
Intricate  macrame  patterns  have  also  been  worked 
out*by  them,  and  delicate  wood-carving  done.  Dr. 
Shuttleworth  once  had  under  his  care  a  patient  of 
this  type,  J.  B.,  who  at  twelve  years  of  age  could  not 
read  or  write,  and  could  do  nothing  beyond  washing 
and  dressing  himself,  which  he  accomplished  with 
difficulty,  owing  to  athetosis.  Two  years  later  he 
was  able  to  read,  write,  and  draw  a  little,  and  could 
make  simple  articles  in  the  joiners'  shop.  After 
ten  years'  training  he  was  an  excellent  joiner,  and 
gained  prizes  for  wood-carving  in  Arts  and  Crafts 
Exhibitions.  Five  years  later  he  had  become  the 
instructor  in  wood-carving.  A  recent  report  states 
that  "  he  is  able  to  explain  his  methods;  is  an  accu- 
rate and  artistic  wood-carver  himself  ;  makes  his 
own  designs  for  panels/'*  It  must  be  remembered, 
however,  that  many  cases  of  cerebral  diplegia  in 

*  See  Plate  XV  i. 


128      MENTALLY  DEFICIENT  CHILDREN 


infants  die  either  from  inanition  or  some  intercurrent 
disease. 

Various  grades  of  mental  defect  from  simple  feeble- 
ness to  crass  idiocy  are  associated  with  paralysis  de- 
veloped after  birth,  and  the  prognosis  varies  with  the 
degree;  the  prognosis  is,  however,  worse  than  in  the 
cases  due  to  injury  at  birth.  In  those  cases  speech 
is  often  bad,  and  this  fact  may  be  misleading.  It 
must  be  remembered  that  they  have  considerable 
will-power,  and  will  persevere  to  overcome  their 
defects.  Attention  must  be  directed  mainly  to  the 
physical  side,  muscular  atrophies  and  contractions 
being  subjected  to  electrical  treatment  and  massage; 
in  the  milder  cases  considerable  improvement,  both 
physical  and  mental,  may  be  anticipated.  The 
postnatal  cases  are  particularly  liable  to  epilepsy; 
should  this  develop,  the  prognosis  is  bad. 

There  are  undoubtedly  cases  of  cerebral  paralysis 
in  children  with  no  intellectual  weakness,  but  they 
are  rare.  Whatever  the  parents  may  think,  we 
usually  find  a  degree  of  mental  irritability,  or  a  ten- 
dency to  epileptic  fits,  or  emotional  weakness,  or  some 
other  slight  mental  peculiarity. 

When  discussing  etiology,  we  referred  to  the  fre- 
quent association  of  syphilis  with  plegic  cases  of 
mental  defect,  which  has  been  suggested  by  the  results 
obtained  with  the  Wassermann  reaction  both  by 
Dr.  Plaut  and  Dr.  Gordon.  Dr.  Gordon,*  after  exam- 
ining 400  cases  of  congenital  mental  deficiency,  of 
which  105  were  plegic  and  295  non-plegic,  found  the 
percentage  of  positive  reactions  to  the  Wassermann 
test  in  plegic  cases  almost  treble  the  percentage  in 
non-plegic  cases — viz.,  31-4  in  the  plegic  as  com- 

*  J.  Leslie  Gordon,  M.D.,  "  The  Incidence  of  Inherited 
Syphilis  in  Congenital  Mental  Deficiency,"  Lancet,  September 
20,  1913. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      129 


•   pared  with  11-2  in  the  others.     As  regards  the  par- 

1   ticular  types  of  paralysis,  excluding  juvenile  general 

paralysis  of  the  insane,  in  which,  as  might  be  expected, 

i   every  case  gave  a  positive  result,  Dr.  Gordon  obtained 

i  positive  results  in  chorea  and  paralysis  in  every  case, 

in  ocular  cases  in  50-0  per  cent.,  in  diplegia  in  48-3  per 

cent.,  in  paraplegia  in  20-4  per  cent.,  and  in  hemi- 

plegia  in  13-6  per  cent. 

In  the  diagnosis  of  Traumatic  cases  the  history  of  a 
fall  or  injury  to  the  head  must  be  accepted  with  dis- 
crimination; but  falls  from  careless  nurses'  arms,  from 
an  overturned  perambulator,  down  stone  steps,  and 
severe  blows  on  the  head,  are  not  improbable  causes. 
The  presence  of  external  swelling  or  haemorrhage, 
or  the  occurrence  of  fits  soon  after  the  accident,  will 
be  confirmatory  evidence.  Sometimes  careful  exam- 
ination with  the  X  rays  will  reveal  some  localized 
thickening  of  the  bone  or  membranes.  The  prognosis 
varies  with  the  severity  of  the  injuries  and  their  con- 
sequences ;  the  influence  of  an  hereditary  tendency  to 
nervous  disease  may  be  an  important  factor.  We 
have  seen  mild  traumatic  imbecility  entirely  recovered 
from  in  the  process  of  growth  and  development ;  the 
resources  of  modern  cranial  surgery  make  the  prog- 
nosis more  favourable  than  formerly. 

Of  the  cases  in  which  the  stigmata  of  Tubercle  are 
strongly  marked,  we  may  say  that  the  prognosis 
varies  with  the  intensity  of  the  taint.  Much  depends 
upon  favourable  environment,  and  it  is  remarkable 
how  such  cases  improve,  both  mentally  and  physi- 
cally, when  withdrawn  from  insanitary  slums  and 
placed  under  good  hygienic  conditions,  especially 
when  employed  in  outdoor  work  in  pure  country  air. 
Post-febrile  or  Inflammatory  cases  are  also  diag- 
nosed by  the  history,  and  the  absence  of  congenital 


130      MENTALLY  DEFICIENT  CHILDREN 

defect.  Here,  again,  a  radiograph  may  help.  Speak- 
ing generally,  the  prognosis  is  not  favourable  in  these 
cases,  though,  of  course,  it  depends  upon  the  amount 
of  damage  the  brain  has  sustained  and  the  degree  of 
atrophy  consequent  on  meningeal  thickening.  In 
some  cases  irremediable  lesions  are  left;  in  others  the 
arrest  of  development  from  failing  nutrition  may, 
tinder  favourable  circumstances,  be  averted.  In  this 
group  should  be  included  the  cases  that  occur  after 
Polioencephalo-myelitis  (infantile  paralysis). 

Of  Emotional  cases,  caused  by  shock  and  fright, 
there  are  many  degrees.  The  history  usually  serves 
for  their  recognition,  while  the  absence  of  the  features 
of  congenital  abnormality,  with  persistent  nervous- 
ness, and  sometimes  a  peculiar  scared  expression, 
will  help  in  the  diagnosis.  Much  good  may  be  done 
by  placing  such  a  patient  in  a  favourable  environ- 
ment with  suitable  training,  and  so  gradually  giving 
him  confidence  in  himself;  we  have  known  children 
who  have  been  victims  of  shock  become,  after  special 
education,  fairly  useful  members  of  society.  Exposed 
to  the  rugged  ways  of  public  schools,  where  they 
may  be  jeered  and  scoffed  at,  there  is  considerable 
risk  of  mental  deterioration. 

Toxic  cases  are  recognised  by  signs  of  failure  in  a 
child,  previously  normal,  who  has  been  dosed  with 
alcohol  or  opium.  The  possibility  of  the  presence  of 
these  and  other  powerful  drugs  in  patent  medicines 
must  not  be  overlooked.  The  lesions  are  of  an 
atrophic  character;  good  results  will  follow  with- 
drawal of  the  poisons,  and  the  substitution  of 
nourishment  appropriate  to  the  child's  age. 

In  the  last  chapter  we  gave  a  full  account  of  the 
pathology  of  the  family  type  of  infantile  cerebral 
degeneration  designated  Amaurotic  Idiocy.  Here  we 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      131 

need  only  say  that  the  diagnosis  depends  on  the 
onset  during  the  fourth  month,  or  thereabout,  of 
weakness  of  the  muscles  and  back  in  a  previously 
healthy  Jewish  infant,  with  difficulty  of  vision.  The 
ophthalmoscope  reveals  changes  in  the  macula  lutea, 
whi^e  later  there  is  optic  atrophy  and  total  amaurosis. 
As  the  disease  progresses,  the  child  is  unable  to  sit  up. 
All  the  muscles  become  weak.  At  a  later  stage  there 
is  muscular  atrophy  and  emaciation.  The  senses  of 
hearing  and  taste  are  preserved,  and  the  thoracic 
and  abdominal  viscera  remain  healthy.  The  prog- 
nosis is  at  present  hopeless,  the  patients  always  suc- 
cumbing within  two  years,  and  often  much  sooner. 

The  condition  occurring  in  older  children,  known 
as  Cerebral  Degeneration  with  Symmetrical  Changes 
in  the  Maculae,  has  also  been  fully  described  in  the 
last  chapter. 

The  features  of  Sporadic  Cretinism  are  so  charac- 
teristic that  there  is  usually  little  doubt  as  to  the 
diagnosis,  which  can  often  be  made  by  the  third 
month.  Dwarfing,  both  of  body  and  mind,  with 
slow  reaction  and  response,  a  loose  baggy  skin,  tumid 
belly,  bowed  legs,  broad,  squat  hands  and  feet,  are 
3me  of  the  general  characters.*  Then  there  is  the 
^uare,  expanded  head,  the  sallow  complexion,  the 
Droad,  flushed  cheeks,  the  indented  "  pug-nose,"  the 

Duting  lips,  and  the  protruding  tongue,  making  up  a 
physiognomy  which  once  seen  is  never  forgotten. f 
Investigation  shows  deficiency  or  absence  of  the 
thyroid  gland,  and  in  many  cases  supraclavicular 
fatty  tumours.  The  prognosis  was,  till  a  few  years 
ago,  most  unfavourable.  Now,  thanks  to  the  experi- 

*  See  Plate  XI.,  p.  79,  and  Fig.  i  on  p.  78. 
f  For  table  of  characteristic  differences  between  Cretinism 
and  Mongolism,  see  pp.  133-134 


132      MENTALLY  DEFICIENT  CHILDREN 


mental  researches  of  Victor  Horsley,  Schiff,  and 
others,  successful  treatment  by  administration  of  the 
thyroid  gland  is  an  everyday  occurrence.  Physical 
and  functional  development  then  proceed  at  a  rapid 
rate,  and  the  mental  hebetude  and  slowness  charac- 
teristic of  these  cases  are  usually  transformed  into  a 
vivacity  and  activity  strangely  contrasting  with  the 
previous  condition. 

In  rare  cases,  however,  while  the  bodily  symp- 
toms disappear  under  treatment,  the  mental  con- 
dition does  not  improve.  Dr.  Tredgold  has  an 
interesting  account  of  two  such  cases  in  his  book 
"Mental  Deficiency."  Some  observers  think  that,  if  a 
normal  condition  is  to  be  attained,  treatment  must  be 
begun  early — at  any  rate,  not  later  than  the  age  of 
twelve  months.  Less  marked  improvement  may,  how- 
ever, be  looked  for  even  when  thyroid  medication  is 
resorted  to  only  in  later  years.  Indeed,  Dr.  Shuttle- 
worth  has  treated  with  considerable  benefit  a  man 
of  forty-two,  who  at  that  age  was  only  3  feet  I  inch 
high,  was  quite  imbecile,  and  suffered  from  lateral 
curvature  of  the  spine.  After  three  years'  thyroid 
treatment  Dr.  Shuttleworth  was  able  to  report  that  he 
"  has  been  transformed  from  an  inert  mass  of  unin- 
telligent matter  to  an  individual  taking  some  interest 
in  his  surroundings,  and  able  to  move  about  and 
investigate  them  for  himself.  His  general  health  has 
improved,  and  his  capacity  for  happiness  and  enjoy- 
ment of  life  has  notably  increased." 

It  would  seem,  however,  that  to  secure  lasting  bene- 
fit the  treatment  must  be  permanent ;  relapse  is  apt  to 
ensue  if  the  thyroid  administration  is  discontinued. 

There  is  a  superficial  resemblance  in  many  cases 
between  Cretins  and  Mongolians,  both  being  back- 
ward in  bodily  development,  with  misshapen  hands 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS       133 


and  feet,  squat  noses,  large  tongues,  and  peculiarities 
of  the  integument.  On  careful  examination,  how- 
ever, the  difference  is  considerable.  The  annexed 
table,  setting  forth  the  characteristic  differences,  may 
be  serviceable,  for  correct  diagnosis  is  of  importance 
to  save  parents  the  disappointment  of  expecting 
marked  improvement  from  thyroid  medication  when 
the  case  is  one  of  mongolism. 


MONGOLISM. 

i.  Characteristics 
able  from  birth. 


notice- 


2.  Skull      brachycephalic : 
contour    rounded    or    short 
oval :  longitudinal  and  trans- 
verse diameters  nearly  corre- 
spond . 

3.  Forehead     usually 
smooth. 

4.  Palpebral  fissures   "  al- 
mond-shaped," and  more  or 
less    oblique     upwards     and 
outwards.        Frequent     epi- 
canthus.       Strabismus   com- 
mon.   Ciliary  blepharitis  fre- 
quent. 

5.  Cheeks    chubby,    often 
florid.    Complexion    mottled. 

6.  Lips  often  transversely 
fissured.     Lower  lip  may  be 
pursed  up  over  upper. 

7.  Tongue        large        and 
coarsely  papillated  if  not  fis- 
sured.      Tongue    frequently 
protruded  and  drawn  back. 


CRETINISM. 

1.  Characteristics        often 
not   noticeable   till   sixth   or 
seventh  month. 

2.  Skull    dolichocephalic  : 
flat  at  top  (fontanelles  close 
late) ,      expanded     laterally ; 
broad    behind,    often    asym- 
metrical. 

3.  Forehead    usually 
wrinkled. 

4.  Palpebral  fissures  hori- 
zontal, but  appear  small  ow- 
ing to  pseudo-oedema  of  eye- 
lids.    Strabismus  and  ciliary 
blepharitis  less  common. 


5.  Often  circumscribed  ma- 
lar flush;  complexion  ashy  or 
waxy. 

6.  Lower  lip  often  everted. 
Mouth  open.  Drivelling  com- 
mon. 

7.  Tongue  large,   but  not 
coarsely    papillated    or    fis- 
sured.   Tip  of  tongue  thick- 
ened,   and    constantly    pro- 
truding. 


134      MENTALLY  DEFICIENT  CHILDREN 


MONGOLISM. 

8.  Skin  smooth  in  infancy, 
but  furfuraceous   later;    not 
redundant  or  "  baggy." 

9.  Hair      "  wiry,"      often 
"  mouse-colour,"    but    some- 
times blonde.  Downy  growth 
common  on  forehead,  cheeks, 
and  neck. 

10.  Thyroid     gland      pal- 
pable to  greater  or  less  ex- 
tent. 

11.  No       fatty      tumours 
(pseudo-lipomata)in  posterior 
triangle  of  neck. 

12.  Long  bones  somewhat 
shorter  than  usual,  but  slen- 
der. 

13.  Hands   broad;    thumb 
and   little   finger   short,    the 
latter  often  curved  towards 
ring  finger.    Fingers  taper  at 
ends. 

14.  Feet    large    and    flat. 
Fissure    between    great    and 
second  toe  often  seen. 

15.  Abdomen     often     dis-l 
tended;  occasional  umbilical/ 
hernia ;  often  inguinal  hernia. 

1 6.  Expression     more     or 
less    vivacious    and    mobile; 
observant  and  imitative. 


CRETINISM. 

8.  Skin     dry     and     scaly; 
forms  folds  here  and  there,  be- 
ing  redundant  and  "  baggy." 

9.  Hair  harsh,  coarse,  and 
scanty.     Usually  of  darkish 
tint  (Bourn eville  says  brown)  ; 
scalp  often  eczematous. 

10.  Thyroid   gland  impal- 
pable to  most  thorough  ex- 
amination. 

11.  Fatty  tumours    (pseu- 
do-lipomata)  frequently  found 
in  posterior  triangle  of  neck, 
etc. 

12.  Long  bones  shortened 
and  thickened,  in  some  cases 
bowed. 

13.  Hands    broad,     thick, 
and  stumpy,   with  wrinkled 
skin.    Fingers  square  at  tips. 


14.  Feet    squat;    skin    re- 
dundant   about    ankles    and 
dorsum  of  foot. 

15.  Abdomen   very   bulky 
and  prominent  with  folds  of 
skin;  umbilical  hernia  com- 
mon. 

1 6.  Expression     dull     and 
immobile ;    unobservant   and 
apathetic. 


Similarities  in  Each  Variety. 

Deficient  stature,  flattened  bridge  of  nose,  with  expanded 
alse,  late  and  irregular  dentition,  deferred  closure  of  fontanelles, 
retarded  puberty  (the  last  most  marked  in  cretins) . 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      135 


A  passing  reference  must  be  made  to  the  rare  class 
of  Achondroplasiaes,  mistaken  sometimes  for  cretins, 
but  not  necessarily  mentally  deficient.  These  are 
usually  intelligent  but  short-limbed  dwarfs,  dis- 
tinguished from  cretins  by  their  "  trident  hands," 
healthy  skin  and  copious  growth  of  hair,  and  also  by 
the  absence  of  "  fat  pads,"  swollen  eyelids,  and 
characteristic  mouth  and  tongue. 

Whilst  setting  forth  the  leading  characters  of  these 
several  groups  as  an  aid  to  diagnosis  and  prognosis, 
it  is  not  pretended  that  we  can  refer  all  cases  of 
mental  deficiency  to  a  single  type.  The  majority, 
indeed,  are  of  Mixed  Types  or  of  no  particular  type 
at  all.  One  of  the  most  unusual  combinations  we 
have  seen  was  a  well-marked  epileptic  microcephalic 
mongolian.  Experience  aids  us  in  distinguishing  and 
assessing  the  value  of  one  factor  and  another  in  their 
combinations.  Thus  traumatism  combined  with  a 
neurotic  family  tendency  is  less  hopeful  as  regards 
mental  improvement  than  when  the  history  is  good. 
A  syphilitic  element  makes  the  outlook  bad,  and  the 
physical  prognosis  of  the  mongolian  with  marked 
phthisical  heredity  or  a  cardiac  lesion  is  most  un- 
favourable. 

Considerable  care  must  be  exercised  at  an  early  age 
in  discriminating  feeble-mindedness  from  retarded 
mental  development  amounting  to  nothing  more  than 
"  backwardness."  In  doubtful  cases  a  definite 
opinion  must  be  withheld,  and  the  child's  develop- 
ment carefully  watched.  The  best  estimate  will  be 
obtained  by  comparing  the  patient  with  a  normal 
child  of  similar  age.  Thus  tested,  a  boy  of  ten  will 
sometimes  be  found  on  an  intellectual  level  with  the 
ordinary  child  of  five;  if  he  has  had  equal  advantages 
with  the  latter,  we  may  fairly  conclude  that  he  is 


136       MENTALLY  DEFICIENT  CHILDREN 


"  mentally  feeble."  M.  Binet  and  Dr.  Simon  regard 
as  defective  in  intelligence  a  child  of  nine  or  more  who 
shows  an  intellectual  retardation  of  three  years.* 
The  physical  accompaniments  previously  alluded  to, 
such  as  developmental  defects,  nerve  signs,  and  low 
nutrition,  may  aid  in  the  diagnosis.  There  may 
often  be  detected  by  the  practised  eye  indications  of 
the  typical  forms — such  as  the  Microcephalic,  Hydro- 
cephalic,  Mongol,  etc. — which  are  more  pronounced 
in  cases  of  actual  imbecility;  while  tubercular,  neu- 
rotic, and,  we  may  add,  rachitic,  affections  are  notice- 
able in  a  large  number  of  children  whose  mental  con- 
dition is  merely  subnormal.  These  signs,  in  conjunc- 
tion with  considerations  of  heredity,  are  of  great  value 
in  the  diagnosis  of  constitutional  defect  of  intelligence 
of  a  minor  degree,  and  also  in  the  prognosis. 

Unfortunately,  there  is  sometimes  associated  with 
mental  defect,  particularly  when  not  early  subjected 
to  proper  training,  moral  weakness,  apt  to  give  much 
trouble  in  after-life.  As  Dr.  Blandford  has  well 
stated  in  his  Lumleian  Lectures  at  the  Royal  College 
of  Physicians: 

"  And  first,  of  those  who,  through  congenital  defect, 
or  as  the  result  Of  disease  in  early  life,  are  mentally 
deficient — not  idiots,  but  weak-minded  imbeciles — 
children  in  mind  throughout  life.  They  come  before 
us  in  various  ways.  Though  children  in  mind,  they 
are  very  often  men  and  women  in  wickedness  and 
vice;  and  it  may  be  necessary  to  place  them  under 
restraint,  or  to  protect  their  property  from  being 
squandered  and  themselves  from  being  robbed.  I 

*  Mentally  Defective  Children,  by  Alfred  Binet  and  Th. 
Simon,  M.D.  Authorised  translation  by  W.  B.  Drummond, 
M.B.,  C.M.,  F.R.C.P.  (Edin.).  London,  Edward  Arnold,  1914, 

P    1 6, 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      137 

know  no  class  over  whom  controversy  is  so  likely  to 
arise,  or  where  we  may  have  greater  difficulty  in 
forming  a  diagnosis.  They  are  not  idiots;  many  of 
them  have  acquired  a  fair  amount  of  education,  can 
construe  a  Greek  play,  or  master  a  proposition  of 
Euclid.  Their  memory  is  excellent,  and  we  cannot 
compare  their  condition  with  a  former  one,  for  they 
have  never  been  any  better,  so  that  this  test  fails  us. 
They  have  no  delusions  or  hallucinations,  and  are  not 
insane  in  the  ordinary  sense  of  the  word.  With 
regard  to  many  there  is  no  difficulty.  When  a  man 
or  woman  of  forty  submits  to  be  treated  like  a  child 
of  ten — to  be  taken  out  and  amused,  and  to  have 
sixpence  a  week  pocket-money — we  have  not  much 
difficulty  in  forming  an  opinion.  But  the  develop- 
ment of  others  is  not  so  low ;  yet  they  are  deficient  in 
reason  and  judgment,  and  often  in  conduct.  There 
is  a  tendency  to  low  and  depraved  habits,  to  brutish 
and  sensual  enjoyment,  to  low  company  amongst 
whom  they  are  of  more  importance,  and  if  remon- 
strated with  they  show  an  absolute  disregard  for  truth 
or  for  right  behaviour.  Lawyers  will  defend  these 
patients  and  say  that  they  are  not  insane,  and  the 
celebrated  Wyndham  case  shows  what  can  be  done 
by  their  aid.  In  examining  any  such  individual  we 
must  consider  his  conduct  in  regard  to  his  environ- 
ment and  bringing  up.  What  might  be  passed  over 
in  the  lower  walks  of  life  is  in  the  higher  evidence  of 
a  degraded  mental  state.  Every  case  must  be  judged 
by  itself,  and  the  question  must  be  asked,  Is  this 
person  able  to  take  care  of  himself  and  his  affairs  ? 
But  to  sign  a  certificate  is  often  very  difficult,  as  we 
may  not  ourselves  witness  the  insane  conduct,  all  of 
which  we  arrive  at  only  by  hearsay.  It  is  not  to  be 
forgotten,  however,  that  imbeciles  are  very  prone  to 


138      MENTALLY  DEFICIENT  CHILDREN 

display  violent  explosiveness  of  their  nerve  centres, 
and  this  is  specially  likely  to  happen  as  they  advance 
from  the  period  of  puberty  to  adolescent  life."* 

The  connection  between  criminality  and  mental  de- 
ficiency is  a  subject  of  vast  social  importance.  It  is 
discussed  in  an  important  section,  "  Mental  Defect 
and  Crime,"  of  the  Report  of  the  Royal  Commission 
on  the  Care  and  Control  of  the  Feeble-minded.  To 
those  interested  in  the  subject  we  would  commend 
the  works  of  W.  D.  Morrison,  Letchworth,  Talbot, 
Havelock  Ellis,  G.  H.  Savage,  and  others,  and  the 
reports  by  Macdonald  to  the  United  States  Bureau  of 
Education.  Lydston's  "  Diseases  of  Society  "  and 
Mercier's  "  Criminal  Responsibility  "  are  two  excel- 
lent text-books.  Many  valuable  papers— notably  one 
by  Dr.  Barr — are  to  be  found  in  the  Proceedings 
of  the  American  State  Committees  on  Charities  and 
Corrections. 

We  cannot  go  into  the  whole  of  this  difficult  sub- 
ject, but  must  explain  that,  while  very  many  of 
the  feeble-minded  gravitate  towards  immoral  and 
antisocial  conduct,  only  a  small  proportion  of  them 
are  really  "  moral  imbeciles."  Take  the  ordinary 
feeble-minded  child  or  youth  away  from  the  bad 
environment  into  which  he  so  readily  drifts,  and 
place  him  in  healthy  and  proper  surroundings  with 
good  discipline;  in  a  short  time  he  will  be  quite  a 
different  creature.  Such  has  been  the  experience  at  the 
Sandlebridge  Schools  of  the  Lancashire  and  Cheshire 
Society  for  the  Permanent  Care  of  the  Feeble-minded. 
Miss  Dendy,  who  was  the  Honorary  Secretary  of  that 
Society  before  becoming  a  member  of  the  Board  of 
Control,  in  answer  to  inquiries  before  the  publication 
pf  our  third  edition,  kindly  wrote  to  say:  "  I  am, 
*  Cancel,  April  6,  1895,  p.  857. 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      139 

however,  as  you  say,  sure  that  in  the  majority  of  cases 
children  who  have  been  supposed  to  be  moral  defec- 
tives do  not  merit  that  title  at  all,  and  do  very  well 
as  soon  as  they  are  removed  from  the  surroundings 
which  have  prompted  their  evil  doings;"  adding: 
"  Many  children  have  been  sent  to  us  at  Sandlebridge 
as  incurably  wicked,  but  we  have  had  to  discharge 
only  one  youth.  He  was  more  lunatic  than  feeble- 
minded, or,  rather,  I  should  say  lunacy  supervened 
on  weakness  of  mind.  Occasionally  we  have  to  iso- 
late a  child  for  a  time,  so  that  it  may  not  contaminate 
the  other  children;  but,  luckily,  bad  habits  are  as 
soon  forgotten  as  good  ones/'  The  true  moral  im- 
becile is,  however,  a  difficult  type.  According  to  the 
Mental  Deficiency  Act,  Moral  Imbeciles  are  "  persons 
who  from  an  early  age  display  some  permanent 
mental  defect  coupled  with  strong  vicious  or  criminal 
propensities  on  which  punishment  has  had  little  or 
no  deterrent  effect." 

As  an  illustrative  case,  we  will  refe.r  to  a  "  youth 
aged  nineteen,  the  son  of  respectable  people.  He 
was  educated  at  an  ordinary  school,  and  subse- 
quently at  a  technical  school,  where  he  exhibited 
special  talent,  especially  for  drawing.  He  writes  an 
exquisite  hand,  and  is  an  expert  in  photography.  He 
has  had  several  situations,  usually  as  a  clerk,  but  if 
he  has  not  been  summarily  dismissed,  he  has  always 
given  them  up  after  a  few  weeks'  work.  He  was  a 
thief  from  an  early  age,  and  has  frequently  been 
caught  in  the  act  at  school  and  elsewhere.  He  has 
several,  times  been  in  the  hands  of  the  police,  and  has 
served  a  term  of  imprisonment.  He  is  utterly  de- 
praved ;  he  lies  in  bed  in  the  morning,  and  spends  all 
the  money  he  can  get  on  drink  and  vice.  He  steals 
from  his  own  family,  and  pawns  the  clothes  with 


140      MENTALLY  DEFICIENT  CHILDREN 


which  he  is  provided.  Although  he  will  not  do 
ordinary  work,  he  spends  hours  in  his  favourite  hobby 
of  enlarging  photographs.  This  he  does,  not  in  the 
usual  way,  but  in  a  manner  suggestive  of  a  mental 
twist,  for  he  makes  a  large  pencil-drawing  of  a  small 
photograph,  and  then  photographs  the  large  drawing. 
So  accurately  is  this  done  that  people  believe  the  en- 
largement to  be  effected  in  the  usual  way.  He  is 
certainly  abnormal,  for  he  has  a  narrow  forehead, 
suffers  from  an  extreme  degree  of  myopia,  and  has  a 
slightly  dilated  heart." 

Essential  features  in  the  diagnosis  are  the  con- 
sideration that  the  crime  is  out  of  all  proportion  to 
the  temptation,  that  the  moral  shortcomings  are  not 
to  be  explained  by  training  and  environment,  and 
are  not  influenced  by  ordinary  discipline  and  punish- 
ment. There  is  usually  some  other  sign  of  defect, 
but  this  is  not  necessarily  of  an  intellectual  nature. 
Often  there  is  a  certain  eccentricity  of  character 
and  a  dislike  of  family  habits;  there  is  frequently  a 
constant  tendency  to  lying,  together  with  bad  sexual 
habits  and  cruelty  towards  companions  and  animals. 
The  crime  of  arson  is  sometimes  an  overpowering 
temptation.  These  cases  are  very  difficult  to  deal 
with,  though  something  may  be  accomplished  by 
prolonged  training  in  favourable  surroundings.  For- 
tunately, real  moral  imbeciles  are  not  common.  It 
is  certain  that  they  form  a  very  small  proportion  of 
the  inmates  of  prisons  and  other  places  of  correc- 
tion. When  Dr.  Potts  conducted  an  investigation 
for  the  Royal  Commission  on  the  Care  and  Control 
of  the  Feeble-minded  into  the  number  of  the  mentally 
defective  in  the  parish  of  Birmingham,  he  reported, 
after  examining  403  prisoners,  of  whom  44,  or  10-9  per 
cent.,  were  defective,  that  "  not  a  single  moral  defec- 


ETIOLOGY,  DIAGNOSIS,  AND  PROGNOSIS      141 


live  was  encountered/'  After  regularly  visiting  the 
Stafford  prison  in  connection  with  a  similar  inquiry 
at  Stoke-upon-Trent,  he  stated:  "  It  was  particularly 
noticed  that  there  were  but  few  moral  imbeciles." 
We  are  not  acquainted  with  any  statistics  showing 
the  proportion  of  moral  imbeciles  in  a  large  group  of 
feeble-minded.  Dr.  Potts*  carefully  studied  during 
a  series  of  years  ninety-seven  consecutive  cases  ad- 
mitted to  a  Magdalen  Home.  He  found  that  thirty- 
seven  were  defective  in  some  way,  and  that,  of  these, 
seven  might  be  fairly  described  as  moral  imbeciles. 
These  seven  morally  defective  girls  were  sharp  and 
intelligent,  but  without  any  sense  of  honour  or 
modesty,  and  were  insusceptible  to  moral  and  re- 
ligious training,  thereby  differing  markedly  from  the 
majority.  Nothing  could  restrain  them  from  lying 
and  from  stealing  from  their  companions.  As  we 
have  already  indicated,  the  prognosis  in  these  cases  is 
bad.  Short  terms  of  training  are  useless,  but  when 
firm  and  judicious  training  can  be  continued  for  a  long 
time  in  proper  surroundings,  improvement  is  some- 
times effected.  It  is  not  impossible  that  there  is  a 
kind  of  moral  centre  in  the  brain,  and  so  these  cases, 
•r  some  of  them,  have  been  compared  with  cases  of 
raphia  or  aphasia.  We  have,  indeed,  seen  moral 
reakness  develop  after  a  head  injury.  If  a  portion 
f  the  brain  is  poorly  developed  at  birth,  or  destroyed 
at  a  later  date,  it  is  not  likely  to  be  replaced  by  healthy 
tissue;  after  a  long  interval  other  portions  may  be 
educated  to  assume  its  functions.  For  instance,  the 
child  without  a  conscience  may  be  taught  that  dis- 
honesty is  unpopular,  and  does  not  pay. 

*   "  The  Problem  of  the  Morally  Defective/'  Lancet,  Oc- 
tober 29,  1904. 


CHAPTER  VI 

THE  PSYCHOPATHIES  OF  PUBERTY  AND 
ADOLESCENCE 

THOUGH  this  work  deals  primarily  with  mentally  de- 
ficient children,  it  has  been  thought  desirable  to  intro- 
duce into  this  edition  a  brief  chapter  dealing  with 
the  abnormalities  showing  themselves  during  puberty 
and  adolescence — a  period  in  general  extending 
from  thirteen  to  twenty-five  years  of  age.  These  are 
ofttimes  closely  connected  with  states  of  congenital 
unfitness,  and,  consequently,  may  be  regarded  as 
complementary  to  the  more  juvenile  defects  previously 
described.  We  are  indebted  to  the  acumen  of  Sir 
Thomas  Clouston  (whose  recent  death  psychiatry  de- 
plores) for  the  earliest  and  most  comprehensive  in- 
vestigations respecting  the  above,  his  classic  work  on 
the  Neuroses  of  Development*  dating  as  far  back  as 
189!.  In  Germany,  Kraepelin  has  grouped  the  signs 
of  juvenile  progressive  mental  deterioration  observed 
at  adolescence  (other  than  those  of  juvenile  general 
paralysis)  under  the  comprehensive  designation  of 
"  dementia  praecox  ";  and  Ziehen,  Fischer,  Jung,  and 
others,  have  dealt  more  especially  with  the  educational 
aspects  of  the  subject. 

Juvenile  General  Paralysis  of  the  Insane  has  been 
referred  to  in  previous  chapters,!  and  it  will  suffice  to 

*  Published  by  Oliver  and  Boyd,  Edinburgh,  and  by  Simp- 
kin,  Marshall  and  Co.,  London,  1891. 

f  See  chap,  iv.,  p.  71,  and  chap.  V.,  p.  125,  etc. 
142 


THE  PSYCHOPATHIES  OP  PUBERTY       143 

mention  here  that  Clouston  fully  describes  under  the 
designation  of  "  developmental  general  paralysis  " 
the  cases  of  two  girls,  aged  seventeen  and  nineteen 
respectively,  the  study  of  which  convinced  him  that 
symptoms  similar  to  those  familiar  to  him  in  the 
general  paralysis  of  insane  adults  were  "  due  to 
hereditary  syphilis  as  the  predisposing  cause,  and  to 
puberty  as  the  exciting  cause,  with  a  neurotic  heredity 
as  an  extra-predisposing  cause."* 

The  degenerative  symptoms  showed  themselves  in 
each  case  at  about  the  age  of  fifteen  by  a  slow  and 
gradual  process  of  enfeeblement  and  mental  "  disso- 
lution/' with  motor  disabilities  progressively  advanc- 
ing/ In  the  first  case  the  sixth  standard  had  been 
reached  at  school;  in  the  second,  the  fourth;  and  in 
each  the  knowledge  attained  was  gradually  lost. 
Mental  hebetude,  indolence,  irritability  of  temper, 
with  occasional  fits  of  passion,  and  a  tendency  to 
uncleanly  habits,  were  amongst  the  early  symptoms 
noticed;  and,  later,  melancholic  symptoms  and  fixed 
delusions.  In  both  cases  there  had  been  arrest  of 
bodily  growth  and  of  the  evolution  of  puberty,  with 
absence  of  menstruation  and  of  mammary  develop- 
ment; the  physiognomy  remained  childlike,  with  a 
vacant  and  listless  expression.  There  was  careless- 
ness as  to  personal  appearance  and  no  sense  of  shame 
or  feelings  of  modesty.  The  speech  was  high  in  pitch 
and  monotonous,  with  tendency  to  wavy,  sing-song 
enunciation,  though  not  markedly  tremulous.  Fibril- 
lary  twitchings  of  the  lingual  and  facial  muscles 
were  observed  during  utterance,  and  there  was  con- 
siderable hesitation  in  protruding  the  tongue.  The 
hands  and  arms  were  awkward  and  shaky  in  the 
coarser  manipulations  and  tremulous  in  the  finer 
*  The  Neuroses  of  Development,  pp.  74-90. 


I44      MENTALLY  DEFICIENT  CHILDREN 


movements.  Grasping  power  was  much  impaired, 
but  not  notably  unequal  on  the  two  sides.  The 
muscular  power  and  co-ordination  of  the  lower  limbs 
were  also  diminished,  and  the  gait  was  slovenly. 
There  was,  however,  no  marked  ataxia,  and  in  the 
younger  case  the  knee-jerks  were  found  exaggerated; 
in  the  older  and  more  advanced  one  completely  absent. 
Common  sensibility  seemed  to  be  impaired.  In  both 
cases  the  pupils  were  dilated  and  unequal,  with 
sluggish  reaction  to  light,  and  there  were  "  Hutchin- 
sonian  "  teeth.  The  older  patient,  whose  degenera- 
tion had  been  going  on  for  five  years  previous  to  her 
admission  to  the  asylum,  died  from  gangrene  of  the 
lower  extremities  six  months  after  her  admission,  her 
mental  enfeeblement  and  muscular  weakness  having 
slowly  but  steadily  progressed.  At  the  autopsy 
slight  adhesion  of  the  dura  mater  to  the  skull-cap  was 
found  along  the  coronal  suture.  "  On  reflecting  the 
dura  mater,  there  were  numerous  fine  threads  of 
adhesion  between  it  and  the  arachnoid  along  the  line 
of  the  pial  veins,  especially  between  the  falx  and  the 
arachnoid.  The  arachnoid  was  milky  and  the  pia 
mater  tough  and  thickened.  On  removing  the  brain, 
it  was  found  to  weigh  34^  ounces.  Of  this  there 
were  4!  ounces  of  fluid,  and  the  cerebellum,  pons,  and 
medulla  weighed  5|  ounces.  The  convolutions  were 
very  well  marked  and  numerous,  and  there  was  only 
slight  atrophy  anteriorly."  Adhesions  of  pia  mater 
were  marked  over  the  convolutions  on  the  under  sur- 
face of  the  frontal  lobe,  and  existed  slightly  on  the 
under  surface  of  the  temporo-sphenoidal,  but  nowhere 
else.  The  two  hemispheres  were  adherent  anteriorly, 
and  the  nerves  of  the  base  bound  down  by  thickened 
membrane.  The  lateral  ventricles  were  much  dilated, 
with  thickened  lining  membrane  showing  a  few 


THE  PSYCHOPATHIES  OF  PUBERTY      145 

granulations,  which  were  also  well  marked  on  the 
surface  of  the  fourth  ventricle.  There  were  also 
adhesions  and'  thickening  of  the  membranes  of  the 
spinal  cord.  On  microscopic  examination  of  fresh 
sections  of  the  brain,  there  was  found  considerable 
thickening  of  the  pia  mater,  with  a  close  network  of 
fine  fibres  in  the  layer  just  below.  A  little  deeper 
there  were  seen  a  considerable  number  of  spider  cells 
of  various  sizes,  and  in  the  deeper  layers  the  nerve  cells 
proper  were  very  much  degenerated,  the  apical  pro- 
cesses of  many  being  absent  or  truncated,  and  most 
of  the  basal  processes  also  gone.  The  nucleus  in  many 
of  the  cells  was  not  to  be  seen,  whilst  in  others  it  was 
vacuolated.  In  the  spinal  cord  the  pia  mater  was 
much  thickened,  and  degeneration  of  the  large  cells 
of  the  anterior  cornua  noted,  and  the  epithelial 
cells  lining  the  central  canal  were  found  largely 
increased. 

We  have  ventured  to  draw  thus  copiously  from 
Dr  Clouston's  observations  both  on  account  of  their 
historical  interest  and  because  they  serve  to  mark 
the  pathological  character  of  the  changes  found  in 
juvenile  general  paralysis,  the  incipient  symptoms  of 
which  (especially  in  the  absence  of  an  authentic  his- 
tory) are  sometimes  confused  with  those  of  original 
defect.  It  is  noteworthy  that  in  each  of  the  two 
cases  described  stress  was  laid  in  the  admission  certifi- 
cates on  the  idiotic  aspect  of  the  patients,  though,  of 
course,  the  history  negatived  the  existence  of  amentia. 
It  is  no  uncommon  experience  for  similar  cases  to  be 
recommended  for  admission  into  training  institutions 
for  imbeciles,  for  which,  of  course,  they  are  utterly 
unfit.  Even  apart  from  a  knowledge  of  the  family 
and  personal  history,  a  correct  diagnosis  may  be 
arrived  at  by  an  observation  of  the  sluggish,  dilated, 

10 


J46      MENTALLY  DEFICIENT  CHILDREN 


unequal  pupils,  sometimes  irregular  in  outline,  and 
of  the  existence  of  fibrillar  tremors  in  the  muscles 
about  the  mouth  and  of  the  tongue.  Stigmata  of 
inherited  syphilis  found  in  adolescence  will  also 
furnish  a  warning  note.  It  is  almost  unnecessary  to 
add  that  the  course  of  juvenile  general  paralysis  is' 
slowly  but  surely  towards  a  fatal  termination.  As 
Tredgold  remarks,  "  Primary  dementia  in  young 
aments  is  of  such  rare  occurrence  that  its  presence, 
without  antecedent  insanity  or  epilepsy,  is  nearly 
always  indicative  of  juvenile  general  paralysis/'* 

Dementia  praecox  is  the  term  used  by  Kraepelin  to 
designate  certain  forms  of  mental  derangement  and 
degeneration  occurring  during  the  period  of  adoles- 
cence in  persons  not  necessarily  recognised  as  defective 
in  their  earlier  years.  Clouston,  who  had  described  a 
similar  train  of  symptoms  under  the  name  of  "  ado- 
lescent insanity  "  more  than  twenty  years  previously, 
lays  great  stress  upon  its  hereditary  character, 
tracing  neuropathic  inheritance  in  65  per  cent,  of  his 
cases;|  and  a  neuropathic  family  history  to  the 
extent  of  from  80  to  90  per  cent,  in  cases  of  dementia 
prsecox  is  alleged  by  German  writers. 

Clouston  calls  adolescent  insanity  "  the  most 
hereditary  of  all  insanities/'  and  considers  that  the 
30  per  cent,  of  such  cases  who  die  demented  were 
"  doomed  to  this  ending  from  the  first  by  their  original 
hereditary  defect."  Yet  up  to  about  eighteen  no 
evidence  of  bodily  or  mental  defect  may  be  apparent, 
though  the  affection  may  be  looked  upon  as  a  con- 
dition of  "  postponed  idiocy/'  evolved  only  just  before 
maturity.  Whether  or  not  dementia  praecox  is  (as 
Kraepelin  considers)  a  pathological  entity  has  been 

*  Mental  Deficiency,  second  edition,  p.  358. 
f   The  Neuroses  of  Development,  p.  116. 


THE  PSYCHOPATHIES  OF  PUBERTY 


keenly  contested;  and  Shaw  Bolt  on*  refers  to  the 
term  as  loosely  applied  to  many  types  of  insanity 
originating  between  puberty  and  maturity.  Accord- 
ing to  Kraepelin,f  the  early  symptoms  are — (i)  list- 
lessness  and  seeming  apathy;  (2)  sensory  sphere 
affected,  as  evidenced  by  dream  perceptions  and  rare 
hallucinations;  (3)  morbid  curiosity  and  inability  to 
sustain  attention  and  connected  conversation;  and 
(4)  memory  good  for  events  and  acquirements  previous 
to  onset  of  affection.  Later,  however,  the  mental 
processes  undergo  deterioration,  the  judgment  is 
affected,  and  delusions  occur.  Verbigeration  and 
stereotypism  are  in  evidence.  Kraepelin  groups 
cases  into  three  varieties,  of  which  the  predominant 
features  are — •  . 

1.  Hebephrenia,  in  which  there  is  a  condition  of 
mental  weakness  developing  into  subacute  disturb- 
ance. 

2.  Katatonia,  in  which  stupor  or  excitement  occurs, 
with  stages  of  auto-suggestibility. 

3.  Paranoia,  in  which  the  demented  condition  is 
slowly  progressive,  attended  with  delusions  and  hallu- 
cinations in  an  otherwise  clear  mind,  with  marked 
tendency  to  negativism.     The  progress  of  the  disease 
often  extends  over  many  years,  and  intermissions  of 
considerable  length  may  occur,  giving  rise  to  fallacious 
hopes  of  recovery.     The  prognosis  is,  however,  un- 
favourable :  Kraepelin  states  that  not  more  than  3  per 
cent,  of  the  hebephrenics  recover,  but  about  20  per 
cent,  of  the  katatonics.     In  certain  stages  the  re- 
semblance to  primary  amentia,  as  regards  weak  will 
and  judgment,  childish  conversation  with  tiresome 

*  Brain  in  Health  and  Disease,  Joseph  Shaw  Bolton,  p.  320. 
f  Lectures  on  Clinical  Psychiatry,  Kraepelin,  translated  by 
Johnstone.    London,  1904. 


148      MENTALLY  DEFICIENT  CHILDREN 


iteration  of  phrases,  may  lead  to  confusion  in 
diagnosis;  but  the  statuesque  postures,  muscular 
rigidity,  increased  reflexes,  hallucinations,  and  un- 
emotional tendencies,  will  serve  to  differentiate  true 
cases  of  dementia  praecox,  which,  however,  may 
occasionally  supervene  in  the  subject  of  primary 
amentia.  A  knowledge  of  the  mental  history  in 
childhood  and  the  existence  of  educational  acquire- 
ment, which  is  not  abrogated  in  the  early  stages  of 
the  dementia,  will,  of  course,  clear  up  the  diagnosis. 

Developmental  Epilepsy  and  Epileptic  Mental  De- 
generation.— Clouston  lays  down  as  an  axiom  that 
"  almost  all  cases  of  true  epilepsy  first  arise  during 
the  growth  and  development  of  the  brain/'*  From 
birth  up  to  the  age  of  seven  Gowersf  found  that  out 
of  1,450  cases  investigated,  340  (or  23  per  cent.)  arose 
during  this  period,  77  (or  5  per  cent.)  during  the  first 
year  of  life.  From  thirteen  to  eighteen,  the  period 
of  puberty  and  early  adolescence,  444  cases  first 
occurred,  about  one-third  of  the  whole.  In  the  last 
seven  years  of  adolescence  (eighteen  to  twenty-five) 
195  (or  only  13  per  cent,  of  all  the  cases)  occurred. 
Infancy,  puberty,  and  early  adolescence  thus  figure 
as  the  markedly  epilepto -genetic  periods,  respect- 
ively those  of  faster  brain  growth  and  most  rapid 
development.  Gowers  and  others  have  traced  neuro- 
pathic heredity  in  from  28  to  35  per  cent,  of  the 
cases  noted.  The  "  discharging  lesion  "  of  the  motor 
cortex  which  Hughlings  Jackson  pointed  out  as  the 
essential  cause  of  epilepsy  implies  imperfect  evolu- 
tion of  co-ordinating  and  inhibitory  apparatus  in 
the  highest  cortical  levels,  which  we  may  consider 
in  most  cases  to  be  an  innate  pathological  condition. 

*  Op.  cit.,  p.  97. 

t  Gowers'  Epilepsy,  first  edition,  p.  12. 


?#£  PSYCHOPATHIES  Of  PUBERTY     149 

Epileptic  nerve-storms  frequently  occurring  produce 
more  or  less  mental  wreckage.  The  effect  of  epilepsy 
in  childhood  has  been  already  considered  (see  pp. 
123-124).  It  remains  to  add  that  in  puberty  and 
adolescence  mental  enfeeblement  of  various  degrees 
is  frequently  produced  in  those  who  begin  to  suffer  at 
this  period  from  oft-repeated  convulsions  or  from  the 
minor  attacks  known  as  "  petit  mal."  There  are, 
however,  exceptions,  for  such  men  as  Julius  Caesar, 
Mahomet,  Peter  the  Great,  and  Napoleon,  are  reputed 
to  have  been  epileptics;  but  there  is  ample  evidence 
that  impairment  of  memory,  judgment,  and  of 
mental  activity  generally,  is  apt  to  follow  such 
attacks,  and  in  extreme  cases  the  previously  intelli- 
gent youth  may  sink  into  a  condition  of  progressive 
dementia,  or  develop  the  more  active  symptoms  of 
epileptic  insanity.  The  diagnosis  of  such  cases  is 
readily  determined  by  the  history;  the  prognosis  is, 
with  few  exceptions,  most  unfavourable,  especially 
when  neuropathic  heredity  is  traceable. 

It  has  been  suggested,  with  a  considerable  degree 
of  probability,  that  in  some  cases  of  so-called  "  moral 
imbecility  "  the  periodical  (and  at  first  sight  inex- 
plicable) outbursts  of  evil  conduct  are  due  to  epilepti- 
form  impulses,  and  cases  have  been  recorded  in  which 
convulsions  and  criminality  seemed  to  alternate  with 
each  other. 

Pubertal  Perversion  of  Moral  Sense. — Apart  from  the 
more  permanent  forms  of  moral  imbecility  previously 
referred  to,  *  one  occasionally  meets  with  cases  in  which 
the  strain  of  puberty  in  its  initial  period  produces, 
especially  in  those  of  neurotic  antecedents,  a  tempor- 
ary lapse  or  perversion  of  moral  sense.  A  well-brought- 
up  youth  of  previous  average  intelligence  and  in- 

*  See  pp.  136-141. 


150      MENTALLY  DEFICIENT  CHILDREN 

tegrity,  during  the  access  of  puberty  may  begin  to 
disregard  the  "  proprieties/'  evolve  hazy  ideas  of 
the  distinctions  between  ,meum  and  tuum,  and  go  on 
to  appropriate  other  people's  goods,  which  possibly 
are  of  no  service  whatever  to  himself.  From  his 
own  family  his  depredations  may  extend  to  outsiders, 
and  a  public  exposure  may  follow,  greatly  to  the  dis- 
may of  his  relatives.  If  in  the  lower  ranks  of  society, 
he  gets  into  the  hands  of  the  police,  and  his  appro- 
priate penal  treatment  puzzles  the  magistrate,  who 
probably  commits  him  to  a  reformatory  or  industrial 
school.  If  of  the  "  upper  classes,"  a  doctor  is  called 
in,  who  diagnoses  kleptomania,  and  the  youth  remains 
in  his  friends'  care,  probably  to  relapse  into  similar 
peccadillos  from  time  to  time.  If,  however,  with- 
drawn from  his  old  surroundings  and  placed  under 
the  judicious  care  of  a  tactful  tutor,  able  to  secure 
his  pupil's  confidence  and  affection,  and  to  interest 
him  in  outdoor  employments  and  sports,  a  gradual 
rehabilitation  of  moral  balance  may  be  looked  for 
as  the  initial  stress  of  puberty  subsides.  We  have, 
indeed,  met  with  such  cases  in  widely  differing  social 
ranks.  Youths  who  have  caused  scandals  at  public 
schools,  not  only  by  pilfering  from  their  school- 
fellows, but  in  one  instance  by  appropriating  articles 
from  the  masters'  common  room,  and  in  another  by 
forging  his  house-master's  signature  to  a  demand 
for  money  from  his  father's  agent,  have  proved 
amenable  to  influences  such  as  are  suggested  above, 
and  have  eventually  become  useful  and  upright 
citizens.  Girls,  also,  who  in  the  general  perturbation 
of  budding  womanhood  have  temporarily  lost  moral 
balance,  descending,  perhaps,  to  degraded  habits  and 
language,  untruthfulness,  and  pilfering— e.g.,  in  one 
case  from  a  servant's  savings-box — have,  under  good 


THE  PSYCHOPATHIES  OF  PUBERTY      151 


management,  retrieved  their  characters  and  grown  up 
self-respecting  and  respected  members  of  society. 
The  prognosis  of  cases  displaying  moral  delinquency 
for  the  first  time  at  puberty  is  not  necessarily  un- 
favourable, but  discrimination  is  needed  as  regards 
family  and  personal  history,  not  always  correctly 
given.  If  instability  can  be  traced  from  childhood, 
especially  when  there  is  a  neurotic  family  history,  the 
prospect  of  recovering  a  proper  moral  tone  is,  of 
course,  less  hopeful.  It  will  be  observed  that  to 
certify  a  person  as  a  moral  imbecile  under  the  Mental 
Deficiency  Act  some  evidence  of  permanent  mental 
defect  existing  "  from  an  early  age  "  is  required. 

Space  does  not  permit  us  to  enlarge  upon  the 
hysterical  affections  which  may  be  taken  as  signs  of 
mental  weakness  in  the  adolescent  period,  more 
especially  of  females.  In  such  cases  whimsical 
fancies  and  perverted  emotional  impulses,  which 
may,  perhaps,  be  regarded  as  reflex  symptoms  of 
inchoate  uterine  function,  give  rise  to  eccentricities 
of  conduct  which  it  may  be  difficult  to  differentiate 
from  adolescent  insanity  save  by  their  more  transient 
character.  In  a  case  recorded  by  Clouston  a  young 
woman  of  twenty  complained  of  "  jumpings  "  all 
over  her  body,  "  cracklings  "  in  the  nerves  of  the 
abdominal  region,  and  "  emptinesses "  in  many 
places  !  Withal  there  was  an  exuberant  religiosity, 
with  an  insensitiveness  to  ordinary  moral  obligations, 
such  as  dutiful  behaviour  towards  her  parents.* 

Insanity  in  Childhood. — Under  this  head  we  may 
very  briefly  consider  symptoms  which  are  sometimes 
passed  over  in  early  life  until  accentuated  at  puberty, 
but  which  point  to  something  more  than  the  ordinary 
negative  characteristics  of  mental  defect.  Con- 

*   The  Neuroses  of  Development,  p.  107. 


152      MENTALLY  DEFICIENT  CHILDREN 

ditions  indistinguishable  from  those  of  mania  and  of 
melancholia  sometimes  occur  in  the  offspring  of 
insane  parents  or  grandparents  long  before  puberty, 
though  in  some  of  these  it  is  probable  that  there  is 
a  premature  development  of  the  reproductive  system. 
The  nerve-storms  to  which  some  children  of  unstable 
brain  action  are  periodically  subject  may  be  properly 
classed  as  of  the  nature  of  maniacal  insanity;  and  in 
other  cases  states  of  depression — of  which  instances 
are  recorded  at  as  early  an  age  as  six — deserve  the 
name  of  melancholia.  The  prognosis  is  invariably 
grave,  such  cases  often  deteriorating  under  the  stress 
of  puberty  and  eventually  gravitating  into  asylums 
for  the  insane. 

Amongst  minor  mental  and  moral  changes  not  infre- 
quently noticed  at  this  period  may  be  mentioned 
lethargic  conditions,  asociability,  causeless  aver- 
sions, ill-temper,  hyper-conscientiousness,  religiosity, 
and  perverted  sexual  trains  of  thought  with  evil 
practices.  These  may  pass  away  as  the  constitutional 
upheaval  subsides,  though  in  cases  of  neuropathic 
inheritance  there  is  risk  of  permanent  mental  de- 
terioration. 


CHAPTER  VII 

MEDICAL  EXAMINATION  OF  MENTALLY  DEFEC- 
TIVE CHILDREN  UNDER  THE  REGULATIONS 
OF  THE  BOARD  OF  EDUCATION 

IN  view  of  the  relations  subsisting  between  the 
Mental  Deficiency  Act — Sections  i  (i),  2  (2),  and 
31  (i) — and  the  Elementary  Education  Acts  relating 
to  defective  and  epileptic  children,  the  Board  of  Edu- 
cation have  issued  a  circular  to  Local  Education 
Authorities,  accompanying  a  scheme  of  model  ar- 
rangements for  ascertaining  the  existence  of  mental 
defect  and  its  degree  in  children  between  the  ages  of 
seven  and  sixteen.  The  principal  provisions  are  as 
follows : 

1.  The  School  Medical  Officer,  and  such  other  duly 
qualified    medical    practitioners    approved    by    the 
Board  of  Education  as  the  Local  Education  Authority 
may  approve  for  that  purpose,  will  be  Certifying 
Officers   under    the    sections    of   both   Acts    above 
referred  to. 

2.  Head- teachers  and  School  Medical  Officers  are 
to  report  to  the  Local  Education  Authority  all  chil- 
dren appearing  properly  to  fall  under  any  of  the 
sections  cited  of  either  of  the  Acts. 

3.  School  Attendance  Officers  are  also  required  to 
report  the  names  and  addresses  of  all  children  not 
in  attendance  at  school  who  appear,  or  are  alleged  to 
be,    defective   within   the   meaning   of   the   Mental 
Deficiency  Act,  1913. 


I54       MENTALLY  DEFICIENT  CHILDREN 

4.  The  Certifying  Officer  is  to  examine,  under  the 
direction  of  the  Education  Authority,  all  such  children 
so  reported,  and  any  child  presented  by  its  parent  as 
requiring  to  be  dealt  with  under  the  Elementary 
Education   (Defective  and  Epileptic  Children)   Act, 
1899.     The   child  is  to   be   examined  within   three 
months  of  his  attaining  the  age  of  seven  years,  and 
at   such  other  times  as  the  Authority  may  deem 
desirable. 

5.  A  certificate  in  the  prescribed  form,  together 
with  a  full  report  of  the  child  on  the  lines  of  the 
schedule  printed   on   pages   168   and   169,  is  to  be 
furnished  to  the  Local  Education  Authority. 

6.  In  the  case  of  children  of  seven  years  or  upwards 
certified  to  be  unfit  for  special  schools  in  consequence 
of  their  being  idiots  or  imbeciles,  copies  of  such  certifi- 
cate and  report  are  to  be  furnished  to  the  Local 
Authority  under  the  Mental  Deficiency  Act,   1913. 
In  any  case  of  proposed  notification  to  the  Local 
Authority  of  a  child  not  certified  to  be  an  idiot  or 
imbecile,  the  Board  of  Education  is  to  be  furnished 
with  a  copy  of  the  report,  and  the  question  whether 
or  not  the  child  shall  be  notified  will,  if  they  think 
fit,  be  determined  by  the  Board. 

7.  In  any  case  in  which  a  defective  child  is  certified 
as  unfit  to  be  instructed  in  a  special  school  or  class 
without  detriment  to  the  interests  of  the  other  chil- 
dren, otherwise  than  on  the  ground  of  being  a  moral 
imbecile  (in  which  case  he  is  to  be  notified  to  the 
Local  Authority),  a  copy  of  the  report  of  the  Certify- 
ing Officer  is  to  be  furnished  to  the  Board  of  Educa- 
tion, who  will  determine,  if  they  think  fit,  whether 
or  not  the  retention  of  the  child  in  the  special  school 
or  class  is  practicable. 

8    The  Local  Education  Authority  is  to  arrange  for 


MEDICAL  EXAMINATION  155 

re-examinations  annually  (at  the  least)  of  all  pupils 
being  educated  in  special  schools  or  classes  with  a  view 
of  ascertaining  (a)  fitness  for  transfer  to  ordinary  ele- 
mentary school;  (b)  incapability  of  further  benefit 
from  special  instruction;  (c)  fitness  for  special  school, 
without  detriment  to  the  interests  of  the  other  chil- 
dren. 

9.  Similar  arrangements  to  apply  to  children  main- 
tained   in    special    schools    not    belonging    to    the 
Authority. 

10.  If  a  child  be  certified  as  incapable  of  receiving 
further  benefit  from  special  instruction,  the  Local 
Education  Authority  will  notify  such  child  to  the 
Local  Authority  under  the  Mental  Deficiency  Act, 
1913,  and  send  copy  of  certificate;  but  if  the  child  be 
not  certified  as  an  idiot  or  imbecile,  it  will  be  neces- 
sary to  furnish  a  copy  of  the  report  to  the  Board  of 
Education,  who  will  determine,  if  they  think  fit,  as 
to  notification  to  the  Local  Authority. 

n.  If  the  Local  Education  Authority  decide  that 
it  is  desirable  that  a  child  over  seven  years  of  age  who 
is  certified  as  capable  of  receiving  benefit  from  special 
instruction  should  be  dealt  with  by  way  of  super- 
vision or  guardianship  under  the  Mental  Deficiency 
Act,  1913,  they  will  notify  the  case  and  the  circum- 
stances thereof  to  the  Board  of  Education;  and  if 
the  Board  certify  that  it  is  desirable  that  the  child  be 
placed  under  supervision  or  guardianship,  the  Local 
Education  Authority  will  notify  the  child  to  the 
Local  Authority  under  the  Mental  Deficiency  Act, 


12.  The  Local  Education  Authority  will  notify  to 
the  Local  Authority  under  the  Mental  Deficiency  Act, 
1913,  any  child  about  to  be  withdrawn  or  discharged 
on  or  before  attaining  the  age  of  sixteen,  in  whose 


156     MENTALLY  DEFICIENT  CHILDREN 

case  they  are  of  opinion  that  it  would  be  for  his  benefit 
that  he  should  be  sent  to  an  institution  or  placed 
under  guardianship  under  the  Mental  Deficiency  Act, 


13.  In  any  cases  under  Clauses  6,  7,  or  10,  in  which 
the  Local  Education  Authority,  notwithstanding  the 
certificate  of  the  Certifying  Officer,  are  opposed  to 
the  child  being  notified  to  the  Local  Authority,  they 
may  refer  to  the  Board  of  Education  to  determine 
the  question.     Similarly  with  regard  to  notifying  a 
child  who   has  not  been  certified  by  the  Medical 
Officer. 

14.  Where  the  Local  Education  Authority  propose 
to  notify  to  the  Local  Authority  under  the  Mental 
Deficiency  Act  blind  or  deaf  children,  reports  both 
from  the  Certifying  Officer  and  the  head-teacher  of 
the  blind  or  deaf  school  attended  must  be  sent  to  the 
Board  of  Education,  who,  if  they  think  fit,  will  deter- 
mine as  to  notification. 

From  a  consideration  of  the  scheme  above  detailed, 
it  will  be  seen  that  increased  responsibility  will  be 
thrown  upon  the  Medical  Officers  of  special  schools, 
and  that  the  time  occupied  by  their  examinations 
will  be  considerably  extended  by  the  necessity  of 
their  filling  up  voluminous  reports,  not  only  on  chil- 
dren presented  for  admission,  but  also  on  those  about 
to  be  withdrawn  or  discharged,  or  considered  to  be 
incapable  of  benefiting  by  further  instruction. 

The  suggested  form  of  report  is  substantially  the 
same  as  that  printed  in  Appendix  C  of  the  Annual 
Report  of  the  Chief  Medical  Officer  to  the  Board  of 
Education  for  1913.*  The  headings  for  inquiry 
therein  relate  to  circumstances  of  environment, 

*  See  Annual  Report,  Chief  Medical  Officer,  Board  of  Educa- 
tion, for  1913,  Appendix  C,  p.  321. 


MEDICAL  EXAMINATION  157 

family  and  personal  history,  physical  and  mental 
conditions,  and  assessment  of  general  intelligence  in 
relation  to  age  by  means  of  the  Binet-Simon  tests. 
These  tests,  formulated  by  Binet  and  Simon  after 
much  experimental  work,  largely  among  normal 
children,  admittedly  rest  upon  a  more  or  less  empirical 
basis;  but  experience  with  them  in  France,  Belgium, 
Germany,  Denmark,  and  in  America  (where  Dr.  God- 
dard  has  published  an  edition  of  them  specially  re- 
vised for  English-speaking  children*),  has  shown  that 
the  results  obtained  in  measuring  the  mental  develop- 
ment of  normal  children  at  various  ages  are  surpris- 
ingly accurate,  and  that  their  application  to  abnormal 
children  reveals  the  degree  of  defect  in  them  as  com- 
pared with  normal  children  of  corresponding  age. 
If  a  child  fails  to  pass  the  tests  appropriate  to  his  own 
age,  but  passes  those  for  a  child  not  more  than  three 
years  younger  than  himself,  he  is,  in  Goddard's  view, 
backward  by  one,  two,  or  three  years ;  but  if  he  is  more 
than  three  years  backward  he  is  mentally  defective. 
These  tests  do  not,  like  ordinary  educational  tests, 
depend  upon  acquired  attainment,  nor  even  upon 
knowledge  merely,  but,  in  the  words  of  Binet,  "  upon 
the  ability  to  use  knowledge  in  meeting  a  situation 
created  by  the  standardised  conditions  of  the  test." 
They  do  not  pretend  to  measure  the  entire  mentality 
of  the  child,  including  the  volitional  and  emotional 
elements,  though  information  as  to  these  may  be 
incidentally  gathered  from  the  way  in  which  the 
examination  is  faced.  It  is,  of  course,  essential  that 
the  examiner  should  by  his  manner  place  the  child 
at  ease  before  applying  the  tests,  and  gain  his  con- 

*  The  Binet-Simon  Measuring  Scale  for  Intelligence,  re- 
vised edition,  1911,  by  Henry  H.  Goddard,  Ph.D.  The  Train- 
ing School,  Vineland,  NJ.  Price  i 


I58      MENTALLY  DEFICIENT  CHILDREN 


fidence  by  pleasurable  suggestions,  such  as  offering 
to  show  attractive  pictures  and  asking  what  he  sees 
in  them,  rather  than  by  plying  him  at  once  with  a 
formal  questionnaire.  In  fact,  the  less  formality 
that  is  compatible  with  a  complete  examination,  the 
more  satisfactory  will  be  the  results.  Replies,  how- 
ever wide  of  the  mark,  must  not  be  openly  stigmatised 
as  wrong:  only  words  of  encouragement  should  be 
used.  Whilst  the  "  standardised  "  form  of  questions 
presented  should  be  strictly  adhered  to,  in  some  cases 
it  may  require  such  explanation  as  may  render  it 
intelligible  to  the  child — e.g.,  in  Question  i  for  age 
eight  it  may  be  necessary  to  explain  that  the  difference 
between  two  things  means  the  points  in  which  they 
are  not  alike.  But  no  hints  as  to  answers  must  be 
given  by  word  or  sign.  Preconceived  ideas  of  the 
child's  abilities  must  be  excluded  from  the  mind  of 
the  examiner,  whose  correct  attitude  is,  in  Goddard's 
view,  "  to  regard  him  as  an  unknown  quantity,  an  x 
which  is  to  be  determined/'  This  dictum  cannot, 
however,  be  intended  to  imply  that  distracting  bodily 
conditions  (e.g.,  toothache  or  headache)  can  be 
ignored;  and  in  the  case  of  mentally  defective  chil- 
dren it  must  be  borne  in  mind  that  mental  fatigue 
may  be  speedily  induced  by  continuous  questioning, 
so  that  it  may  be  advisable  in  certain  cases  not  to 
take  the  whole  examination  at  one  sitting.  The 
tests  of  Binet  and  Simon  grouped  according  to  age 
(as  revised  in  1911)  are  printed  in  Appendix  C  of 
the  Chief  Medical  Officer's  Report  for  1913,  pp.  323, 
324,  and  will  be  found  to  differ  slightly  from  the 
arrangement  by  Dr.  Goddard  previously  referred  to. 
As  the  Chief  Medical  Officer  judiciously  remarks 
(p.  214,  note) :  "  There  is  need  for  much  research  and 
co-operation  in  order  to  revise  our  mental  tests  and 


MEDICAL  EXAMINATION  150 


standardise  them  on  various  types  of  children.  The 
Binet  tests,  which  are  recommended  in  the  Board's 
schedule,  are,  it  should  be  remembered,  tentative, 
and  not  yet  standardised  for  English  use."  Dr.  Kate 
Fraser,  formerly  Assistant  Medical  Officer,  Govan 
School  Board,  and  now  Deputy  Commissioner  of  the 
Scottish  Board  of  Control,  has  published  a  valuable 
paper  (School  Hygiene,  May,  1913)  on  the  use  of  the 
tests  in  determining  the  suitability  of  a  child  for  ad- 
mission to  a  special  school;  and  there  is  no  doubt  that 
these  tests,  judiciously  employed,  in  conjunction 
with  the  results  of  clinical  examination,  and  a  con- 
sideration of  environment  and  family  history,  to- 
gether with  the  experience  of  the  teacher  as  to  the 
child's  educational  capacity,  will  prove  to  be  of  con- 
siderable aid  in  the  diagnosis  and  differentiation  of 
mental  defect.  The  competence  of  the  examiner 
rightly  to  administer  the  tests  is  of  course  a  sine  qua 
non,  and,  though  any  intelligent  teacher  may  easily 
attain  the  needful  technique,  any  bias  from  knowledge 
of  a  child's  educational  acquirements  must  be  guarded 
against.  The  medical  examiner  must  therefore  be 
personally  familiar  with  the  procedure  and  with  the 
inferences  to  be  drawn  from  the  results  obtained.  It 
has  been  pointed  out  by  Dr.  Kuhlmann,  in  an  inter- 
esting contribution  to  the  Journal  of  Psycho- Asthenics 
(June,  1912),  that  the  Binet-Simon  tests  are  valuable, 
not  only  in  differentiating  mentally  defective  children, 
but  in  grading  them  for  class  instruction,  and  also  in 
gauging  their  capability  of  improvement. 

Space  will  not  permit  of  a  detailed  description  of 
the  Binet-Simon  system  of  tests,  but  those  desiring 
a  more  complete  knowledge  of  the  subject  are  referred 
to  Goddard's  pamphlet  previously  referred  to;  to 
Binet 's  papers  to  be  found  in  successive  numbers  of 


160      MENTALLY  DEFICIENT  CHILDREN 

L'Annee  Psychologique,  from  1905  to  1911;  and 
to  Dr.  DrummoncTs  authorised  translation  of  Binet 
and  Simon's  Mentally  Defective  Children,  which  has 
recently  appeared  (London:  Edward  Arnold,  1914). 

Whilst  recognising  the  value  of  the  Binet-Simon 
system  judiciously  used  in  conjunction  with  clinical 
methods  and  scientific  scrutiny  of  the  family  history, 
we  fully  agree  with  the  dictum  of  Dr.  Walter  E. 
Fernald,  the  experienced  superintendent  of  the 
Massachusetts  Institution,  that  "  the  determination 
of  mental  defect  cannot  be  made  by  automatic  appli- 
cation of  any  method  and  scale/'*  In  the  suggested 
form  of  report  on  children  examined  for  mental 
deficiency,  appended  to  the  "  Model  Arrangements  " 
issued  by  the  Board  of  Education,  information  is 
required  as  to  social  surroundings,  family  and  per- 
sonal history,  general  physical  conditions,  including 
also  the  efficiency  or  otherwise  of  the  special  senses, 
the  state  of  the  nose  and  throat  and  of  spinal  re- 
flexes, the  existence  of  physical  stigmata,  etc.  "  In 
assessing  mental  conditions,  the  tests  designed  by 
Binet  and  Simon  are  recommended,"  and  in  the  course 
of  their  application  observations  may  be  made  with 
regard  to  the  activity  or  otherwise  of  such  reactions 
of  motor  mechanism  as  are  involved  in  the  (i)  forma- 
tion and  (2)  storage  of  motor  ideas;  in  (3)  power 
of  control,  initiative,  purpose,  and  concentration; 
(4)  motor  incompetence,  as  shown  by  attitude,  gait, 
and  general  balance;  (5)  motor  instability,  as  evi- 
denced in  uncouth  habits;  and  (6)  motor  disturbance, 
under  which  are  included — tremors  (such  as  Dr. 
Warner  designates  "  abnormal  nerve  signs  "),  chorea, 
epilepsy,  aphasia,  and  hemiplegia.  Then  come 
"  reactions  resulting  from  sensory  stimulation/'  in- 

*  Journal  of  Psycho- A  sthenics,  vol.  xviii.,  No.  2,  p.  80.. 


MEDICAL  EXAMINATION  161 


eluding — (i)  Attention,  as  ascertained  by  the  dis- 
crimination of  colours,  shape,  size,  and  odours; 
(2)  formation  of  memory  images,  as  ascertained  by 
(a)  recognition,  (b)  recollection,  of  objects  and  sounds; 
(c)  association  of  ideas;  (d)  judgment,  as  tested  by 
appreciation  of  length,  size,  and  distance ;  (e)  relation- 
ship, in  comprehension  of  similarity,  contrast,  sym- 
bolism. Emotional  conditions,  as  demonstrated  by 
interest,  excitement,  aggression,  co-operation,  affec- 
tion, etc.,  are  to  be  observed  and  noted.  Then 
follows  a  list  of  tests  of  intelligence  based  upon  edu- 
cational capacity,  and  finally  an  estimation  of  the 
will-power  and  moral  characteristics.  Upon  the  data 
so  obtained  a  diagnosis  is  founded  under  nine  cate- 
gories, some  of  which  may  be  correlated.  Finally, 
"  recommendations  as  to  treatment  "  are  to  be  made 
under  the  following  headings  of  the  class  of  instruction 
desirable : 

1.  An  ordinary  public  elementary  school. 

2.  A  special  class  for  dull  and  backward  children. 

3.  A  special  school  (day  or  residential). 

4.  Unsuitable  for  a  special  school. 

Forms  of  certificate  to  meet  the  needs  of  the  various 
classes  diagnosed  are  prescribed  by  the  Board  as 
follows : 

A.  u  I  certify  that  this  child  is  not  incapable,  by 
reason  of  mental  defect,  of  receiving  benefit  from  the 
instruction  in  an  ordinary  public  elementary  school/' 

B.  "I  certify  that  this  child,  not  being  merely  dull 
or  backward,  and  not  being  an  idiot,  an  imbecile,  or 
a  moral  imbecile,  is  feeble-minded  within  the  meaning 
of    the    Mental    Deficiency  Act,   1913,   but    is    not 
incapable,  by  reason  of  mental  defect,  of  receiving 
benefit  from  instruction  in  a  special  school  or  class 

ii 


1 62      MENTALLY  DEFICIENT  CHILDREN 

under    the    Elementary  Education    (Defective   and 
Epileptic  Children)  Act,  1899." 

C.  "  I  certify  that  this  child  is  incapable,  by  reason 
of  mental  defect,  of  receiving  benefit  from  instruction 
in  a  special  school  or  class  under  the  Elementary 
Education  (Defective  and  Epileptic  Children)  Act, 
1899."     "Note. — Under  the  last-named  Act,  idiots 
and  imbeciles  are  excluded  from  special  schools  and 
classes  certified  under  that  Act." 

D.  "  I  certify  that  this  child  is  incapable,  by  reason 
of  mental  defect,  of  receiving  further  benefit  from 
instruction  in  a  special  school  or  class  under  the 
Elementary    Education    (Defective    and    Epileptic 
Children)  Act,  1899." 

E.  "  I  certify  that  this  child  cannot  be  instructed  in 
a  special  school  or  class  under  the  Elementary  Educa- 
tion (Defective  and  Epileptic  Children)  Act,  1899,  with- 
out detriment  to  the  interests  of  the  other  children." 

Other  forms  of  certificate  are  prescribed  for  epi- 
leptic, physically  defective,  blind,  and  deaf  children ; 
and  there  are  also  forms  of  recommendation  to  be 
employed  by  the  Medical  Officer  when  he  is  of  opinion 
that  a  child  in  a  special  school  should  be  dealt  with 
under  the  Mental  Deficiency  Act,  1913,  by  way  of 
supervision  or  guardianship,  or,  when  about  to  be 
withdrawn  or  discharged,  should  be  sent  to  an  insti- 
tution or  placed  under  guardianship,  in  each  case  the 
reasons  for  such  opinion  being  fully  set  forth. 

The  summary  just  given  of  the  procedure  offi- 
cially prescribed  renders  superfluous  much  that 
appeared  in  the  last  edition  of  this  work  as  to  the 
medical  examination  of  children  requiring  special 
instruction.  With  regard  to  the  technique,  it  may 
be  noted  that,  in  addition  to  appliances  such  as  are 
needed  in  the  medical  inspection  of  ordinary  schools 


PLATE  XVII. 
Dr.  E.  S.  Pasmore's  "Flag"  Chart  of  Heredity 


(Report,  Royal  Commission  on  Care  and  Control  of  Feeble-minded,  Vol.  II.,  p.  531. 
Reproduced  by  kind  permission.) 


Name 


Date... 


EXPLANATORY  NOTES  FOR  USING  CHART. 


1.  Each  flag  denotes  particular  class   of  relative   (e.g.  Grandparents,  Aunts,   etc.):   male  rela 
ndicated  by  shading  ;  female,  plain. 

2.  Number  of  relatives  in  each  class  noted  by  figure  in  corner  of  flag  next  pole.      Those  affected 
leritable   maladies  denoted    by   line,   having   name   of  malady,   drawn   through    flag   appropriate 
elationship. 


To  face  1>age  163. 


MEDICAL  EXAMINATION  163 

— e.g.,  weighing  machine,  height  standard,  and  various 
instruments  for  ascertaining  the  general  conditions, 
physical  and  sensorial,  of  the  patient — it  will  be 
necessary  to  be  provided  with  material  for  the  Binet- 
Simon  tests,  which  can  be  readily  constructed  or  may 
be  obtained  in  sets  (as  arranged  by  Dr.  Goddard) 
from  the  C.  H.  Stoelting  Company,  121,  North  Green 
Street,  Chicago,  111.,  U.S.A.  In  the  Report  for  1913 
of  the  Chief  Medical  Officer,  Board  of  Education 
(p.  214) ,  the  outfit  of  the  psychiatric  clinic  of  the  school 
service  at  Stoke,  as  arranged  by  Dr.  Robert  Hughes, 
is  noted  as  a  model  for  Medical  Officers  engaged  in 
similar  work  elsewhere. 

With  regard  to  special  points  in  the  model  schedule, 
the  following  remarks  may  be  found  serviceable : 

II.  Home  Conditions  should  be  stated,  if  practicable, 
in  terms  of  the  rooms  occupied  and  number  in  family. 
School  attendance  should  be  definitely  ascertained  as 
to  date  of  commencement,  regularity  or  otherwise  of 
attendance,  and  type  of  school. 

III.  Family  History. — As  the  statements  of  rela- 
tives are  apt  to  be  vague  and  diffuse,  particularly 
with  regard  to  mental  and  nervous  defects,  the  em- 
ployment of  some  such  scheme*  as  that  suggested  by 
Dr.  Pasmore  (set  forth  opposite)  is  serviceable  in  giving 
precision  to  information  collected.     In  the  flag  cor- 
responding to  each  member  of  the  family  may  be 
written  alive  (a.)  or  dead  (d.) ;  in  the  latter  case  the 
age  and  cause  of  death  should  be  noted. 

The  question  of  alcoholism  is  always  a  difficult  one 

to  deal  with,  and,  unless  notorious  drunkenness  exists, 

this  factor  in  its  less  conspicuous  manifestations  is 

apt  to  be  overlooked.     Even  present  teetotalism  is 

I  not  always  a  guarantee  against  the  existence  of  alco- 

C'ic  excess  in  the  past.     The  examiner  must  needs 
*  Plate  XVII. 


1 64      MENTALLY  DEFICIENT  CHILDREN 

be  content  with  recording  such  information  as  the 
relative  in  attendance — usually  the  mother — deigns 
to  give,  and  she  is  not  likely  to  give  evidence  against 
herself.  Such  questions  as,  "Are  you  a  beer  or  spirit 
drinker;  and  if  so,  when  do  you  take  your  drink  ?" 
may  sometimes  elicit  suggestive  information  about 
drinking  habits,  but  excess  must  not  be  too  hastily 
assumed  without  reliable  evidence ;  and  caution  in 
stating  in  a  document  such  as  that  prescribed  by  the 
Board  of  Education  that  alcoholism  exists  in  a  par- 
ticular relative  seems  specially  necessary  unless  con- 
clusive proof  is  available. 

The  points  to  be  noted  under  IV.  Personal  History, 
and  under  V.  Physical  Conditions,  are  so  fully  de- 
tailed in  the  schedule  as  to  require  no  comment ;  but 
with  regard  to  VI.  Mental  Conditions  a  few  remarks 
may  be  hazarded.  What,  for  instance,  is  meant 
(under  VI.  a.  3)  by  "  execution  of  familiar  complex 
movements  "  ?  The  seven-years-old  test  in  the  Binet 
Simon  scheme  would  seem  to  supply  an  answer  in  i 
instruction  to  a  child,  which  runs  as  follows: 
and  put  this  key  on  that  chair.  Then  close  the  dc 
Then  take  the  key  which  is  lying  on  the  chair  ne 
the  door,  and  bring  it  to  me.  First  put  the  key 
the  chair,  then  close  the  door,  then  bring  the  key  to 
me."  Goddard  places  this  test  amongst  those  for 
six  years  of  age,  stating  that  at  five  years  of  age  about 
half  the  number  of  (normal)  children  tested  succeed: 
"  at  six  all,  or  nearly  all,"  can  accomplish  this  triple 
commission.  Most  of  the  "  reactions  resulting  from 
sensory  stimulation  "  mentioned  under  VI.  (I)  are 
also  ascertained  in  the  course  of  applying  Binet 's 
tests;  and  consequently  it  is  a  good  plan  to  submit 
the  child  to  these  tests  previous  to  filling  up  the  items 
headed  VI.  Mental  Conditions. 


MEDICAL  EXAMINATION  165 

It  cannot  be  denied  that  up  to  the  present  time 
children  have  found  their  way  into  special  schools 
for  defectives  who  are  not  the  subjects  of  essential 
mental  defect,  though  displaying  a  certain  amount  of 
mental  abnormality  as  compared  with  ordinary 
school-children.  In  some  cases,  especially  in  young 
children,  it  is  difficult  to  determine  with  any  degree 
of  certainty  how  far  incapacity  to  benefit  by  the 
ordinary  school  curriculum  is  due  to  retarded  de- 
velopment rather  than  to  actual  initial  defect.  In 
the  differentiation  between  cases  of  "  spurious  "  and 
real  defectiveness,  the  Binet-Simon  tests  are  service- 
able, and,  conventionally,  a  child  of  nine  or  upwards 
whose  mental  age  is  not  more  than  three  years  behind 
his  actual  age  may  be  considered  backward,  but  a 
greater  difference  shows  mental  defect*  Apart  from 
this,  retarding  causes  may  be  usually  discovered,  such 
as  bad  environment,  irregular  school  attendance, 
physical  defects — especially  adenoids,  defective  vision 
or  hearing — and  sometimes  partial  incapacities,  such  as 
inferior  power  of  calculation  with  fair  ability  in  other 
directions.  In  consequence  of  one  or  more  of  these 
conditions,  those  affected  prove  incapable  of  bene- 
fiting by  elementary  school  instruction  suitable  for 
the  average  child,  and  lag  behind  the  educational 
standards  appropriate  to  their  age.  In  fact,  ordinary 
school  methods  prove  ineffectual  for  their  improve- 
ment, and  the  question  arises,  especially  when  beyond 
the  age  for  infant  departments,  What  steps  can  be 
taken  for  their  advancement  ?  For  such  children 
the  general  establishment  of  backward  classes  or 
intermediate  schools  (as  in  the  Mannheim  educational 
system)  becomes  an  urgent  desideratum,  the  essential 

*  Mentally  Defective  Children,  Binetand  Simon  (Drummond's 
translation),  p.  16. 


1 66      MENTALLY  DEFICIENT  CHILDREN 

conditions  being  small  classes,  a  larger  proportion 
physical  and  manual  training  in  the  curriculum,  and 
such  individual  attention  as  the  peculiarities  of  ea 
case  may  require.  In  cases  mentally  backward 
owing  to  physical  weakness,  open-air  schools,  wit 
their  comparatively  restful  arrangements,  often  pro\ 
very  beneficial.  Unfortunately,  "  backward  classes  : 
are  only  to  be  found  at  present  in  about  a  dozen  edu- 
cational areas  in  England  and  Wales ;  and  the  result 
of  want  of  appropriate  provision  elsewhere  is  that 
backward  children  are  apt  to  gravitate  to  specia 
schools  (where  they  exist),  as  these  are  the  only  ones 
available  by  which  they  can  benefit,  though  it  is  mani- 
festly unjust  to  such  children  that  they  should  be 
stamped  with  the  stigma  of  mental  defect.  It  would 
seem  to  be  the  duty  of  medical  examiners  to  report, 
with  regard  to  children  of  proved  incapacity 
benefit  by  instruction  in  the  ordinary  school  fron 
causes  such  as  are  mentioned  above,  that  they  need 
a  modified  curriculum,  in  the  hope  that  educationa 
authorities  may  see  the  desirability  of  establishk 
special  classes  for  the  dull  and  backward,  in  addition 
to  those  for  the  mentally  defective.  Dr.  Kerr  pointed 
out  (L.C.C.  Educational  Reports,  1905-1906)  ten  ye 
ago  that  a  large  percentage  of  children  attendir 
elementary  schools  in  London,  "  although  not  actually 
'  mentally  defective/  are  yet  of  such  a  low  grad 
mentally  that  they  are  neither  capable  nor  worth  tt 
effort  of  being  raised  to  the  ordinary  elementa 
school  standard/'  and  that  for  such  simpler  school; 
the  "  intermediate  schools  "  of  the  Mannheim  educa- 
tional system — were  required,  in  which,  so  far 
ordinary  scholastic  attainment  is  concerned,  Stan- 
dard IV.  should  be  deemed  sufficient;  while  objective 
teaching,  with  physical  and  manual  training,  should 


MEDICAL  EXAMINATION  167 

be  the  predominant  element.  The  Chief  Medical 
Officer  of  the  Board  of  Education  has  consistently 
advocated  in  his  Annual  Reports  the  formation  of 
"  backward  classes/'  and  in  his  Report  for  1913  con- 
siderable space  is  devoted  to  the  discussion  of  the 
question.  Pending  the  more  general  establishment 
of  classes  or  centres  for  "  intermediate  "  instruction, 
it  seems  inevitable  that  the  resources  of  the  "  special 
school  "  should  be  utilised  for  certain  "  probationary  " 
cases,  with  the  safeguard  of  systematic  scrutiny  as  to 
their  fitness  or  otherwise  for  an  ordinary  school  at 
successive  annual  examinations. 

Under  the  operation  of  the  Elementary  Education 
(Defective  and  Epileptic  Children)  Act  of  1914,  Local 
Education  Authorities  generally  will  be  charged  with 
provision  for  the  education  of  all  mentally  defective 
children,  belonging  to  their  area,  over  seven  years  of 
age,  subject  to  consultation  with  the  parents  in  each 
case  as  to  their  wishes  and  ability  to  make  suitable 
provision.  It  remains  to  be  seen  how  this  proviso 
will  work  in  practice,  but  it  will  be  an  additional 
reason  for  increased  care  in  classification,  and  will 
call  for  much  tact  as  well  as  accuracy  on  the  part  of 
the  medical  examiner.  As  Section  6  makes  it  com- 
pulsory on  the  latter,  if  the  parents  so  request,  to 
consult  with  the  head-teacher  of  the  school  previously 
attended  by  the  child,  it  seems  desirable  that,  in  all 
cases  in  which  the  child  has  attended  an  elementary 
school,  a  careful  written  report  by  the  head-teacher 
should  be  available  at  the  examination  and  be  duly 
considered. 


Overleaf  will  be  found  print  of    "Model  Arrangements" 
(Schedule  F),  previously  alluded  to  in  this  chapter. 


168      MENTALLY  DEFICIENT  CHILDREN 


"  MODEL     ARRANGEMENTS "     (BOARD      OF 

EDUCATION  CIRCULAR  829). 

SCHEDULE  F. 

SUGGESTED    FORM   OF   REPORT   ON   CHILD    EXAMINED    FOR 
MENTAL  DEFICIENCY. 

I.  Name   of   Child    (in   full).     Address.     Date   of   Birth. 

School  (if  any).     Local  Education  Authority. 
II.  Particulars  of  Home  Conditions,  Environment,  School 

Attendance,  and  other  Factors.   . 

III.  Family  History  (in  regard  to  history  of  mental  defect, 

epilepsy,  alcoholism,  etc.). 

IV.  Personal  History :   (a)  Constitutional  Defects,  Injury  at 

Birth,  Malnutrition,  Rickets,  Congenital  Syphilis,  etc. 
(b)  Diseases  of  Childhood,  (c)  Commencement  of 
Teething,  (d)  Walking,  (e]  Speech. 

V.  Physical  Conditions:  (d)  General  (results  of  routine 
medical  inspection),  (b)  Special: — (i)  Speech:  De- 
fective articulation.  (2)  Sight:  Blindness,  total  or 
partial,  errors  of  refraction.  (3)  Hearing:  Deaf- 
mutism,  partial  deafness,  partial  mutism.  (4)  Nose 
and  throat:  Enlarged  tonsils,  adenoids,  mouth 
breathing.  (5)  Control  of  spinal  reflexes  and  of  sali- 
vation, (c)  Stigmata: — (i)  General  retardation — 
Cretinoid  development.  (2)  Cranium  —  Microce- 
phaly, hydrocephaly ,  asymmetry,  rickets,  imperfect 
closure  of  fontanelles,  simple  head  measurement. 

(3)  Hair — Double  and  treble  vortices,  wiry  or  supple. 

(4)  Face — Irregularity  of   features.     (5)  Lower   jaw 
— Protruding    or    receding.       (6)  Eyes — Mongoloid, 
presence  of  epicanthic  fold.     (7)  Ears — Size,  setting, 
conformation,  lateral  symmetry,  size  of  lobes,  attach- 
ment of  lobe  to  the  cheek,  supernumerary  lobules. 

(8)  Tongue — Enlarged,   furrowed,   papillae   enlarged. 

(9)  Teeth — Irregular,  absent,  enlarged  incisors.      (10) 
Palate — Arched,     narrow.      (n)    Fingers — Webbed, 
clubbed,  defective  in  number  or  shape,  supernumer- 
ary digits.     (12)  Limbs — Excessive  length  of  upper 
limbs. 

VI.  Mental  Conditions: 

[N.B. — In  assessing  mental  conditions,  the  tests 
designed  by  Binet  and  Simon  are  recommended.] 

(a)  Reactions  of  Motor  Mechanism: — (i)  Forma- 
tion of  Motor  Ideas.  (Execution  of  simple  move- 
ments from  imitation.)  (2)  Storage  of  Motor  Ideas. 


MEDICAL  EXAMINATION  169 

(Execution  of  simple  familiar  command  by  word  of 
mouth.)  (3)  Power  of  control,  initiative,  purpose, 
and  concentration.  Success  of  motor  output.  (Exe- 
cution of  familiar  complex  movement.)  (4)  Motor 
Incompetence.  Attitude  in  standing  position  of 
head,  spine,  knees.  Gait.  Position  of  arms,  hands, 
fingers,  in  horizontal  extension.  General  balance, 

(5)  Motor  Instability.     (Habits.)     Rocking  of  body, 
rubbing  hands,  spitting,  biting  nails,  or  licking  lips. 

(6)  Motor     Disturbance.      Tremors     (face,     hand, 
tongue),    Chorea,    Epilepsy,    Aphasia,    Hemiplegia. 
(b)   Reactions  resulting  from  Sensory  Stimulation: — 
(i)  Attention — colour,  shape,  size,  smell.     (2)  For- 
mation  of  Memory   Images  :    (a)   Recognition;   ob- 
jects, sounds,     (b)   Recollection.     (3)  Association  of 
Ideas.     (4)   Judgment    (for    example — length,    size, 
distance).     (5)   Relationship     (similarity,     contrast, 
symbolism).     (6)  General  concepts  (possession,  self- 
protection,   purpose,   concentration,   initiative),     (c) 
Emotional  Conditions:  Interest,  excitement,  aggres- 
sion, co-operation,  affection,  etc.  (positive  or  negative 
phases),     (d)  Tests  of  Intelligence:    (i)  Description 
of  pictures,   models,    objects,    familiar   events.     (2) 
Letters,  words,  reading  (word  blindness) .    (3)  Count- 
ing, manipulation  of  simple  numbers,  simple  money 
values.     (4)  Writing.      (5)  Manual  Tests,     (e)  Will 
Power  as  tested  under  the  above  headings.    (/)  Moral 
characteristics  not  recorded  in  (a)  to  (e) . 

VII.  Diagnosis: — (a)  Physically  defective — stating  defect. 
(b)  Blind  or  partially  blind,  (c)  Deaf-mute  or  semi- 
mute  or  semi-deaf,  (d)  Epileptic,  (e}  Merely  dull 
or  backward.  (/)  Mentally  defective  (feeble-minded). 
(g)  Imbecile,  (h)  Moral  Imbecile,  (i)  Idiot. 

[In  this  group  the  symbols  (a)  to  (i)  are  intended 
to  be  correlated  when  necessary.] 

VIII.  Treatment  recommended.  (With  any  necessary  notes 
as  to  after-care,  custody,  and  the  degree  and  char- 
acter of  manual  training  and  ordinary  school  teach- 
ing likely  to  be  advisable.)  (i)  An  ordinary  public 
elementary  school.  (With  or  without  particular 
supervision  or  modification  of  curriculum.)  (2)  A 
special  class  for  dull  or  backward  children.  (3)  A 
special  school  (state  whether  day  or  residential  is 
recommended).  (4)  Unsuitable  for  a  special  school. 

Signature  of  the  Medical  Officer 

Date 


CHAPTER  VIII 

THE  TREATMENT  OF  MENTALLY  DEFICIENT 
CHILDREN 

(a)  GENERAL.     (6)  MEDICAL,     (c)  SURGICAL. 

THE  treatment  of  mentally  deficie'nt  children  is 
essentially  (to  borrow  a  term  from  the  French) 
medico-pedagogic.  The  physician,  the  teacher,  and 
the  nurse,  must  all  co-operate  in  the  ameliorative 
process,  and  the  judicious  parent  will  best  secure 
the  interests  of  his  afflicted  child  by  placing  hir 
where  the  efforts  of  the  three  can  be  co-ordinated. 
As  a  matter  of  convenience,  however,  we  shall  con- 
sider in  order,  first  the  general  treatment,  including 
nursing  and  domestic  management,  and  after  that 
such  treatment  as  belongs  to  the  domain  of  medicine 
and  surgery,  reserving  for  a  subsequent  chapter 
matters  educational. 

Congenital  defect  in  the  young  infant  having  been 
diagnosed,  are  there  any  means  available  for  modify- 
ing its  accompanying  abnormalities  ?  Much,  indeed, 
may  be  done  by  a  loving  mother,  who  will  be  patient 
enough  to  persevere,  in  spite  of  apparently  slight 
results,  to  promote  sensorial  development  and  co- 
ordinate movement,  and,  as  months  go  on,  to  foster 
habits  of  cleanliness.  The  faculty  of  attention,  too, 
may  be  cultivated,  the  child  being  coaxed  to  fix  its 
gaze  on  one  thing  at  a  time.  The  aid  of  music  is 

170 


TREATMENT  OP  MENTALLY  DEFICIENT    171 

often  serviceable,  and  even  idiots  will  respond  in  a 
remarkable  way  to  congenial  sounds,  which  they  at 
length  try  to  imitate,  so  that  music  is  sometimes  the 
stepping-stone  to  speech.  Seguin  has  laid  down  the 
principles  on  which  to  proceed  in  the  following  para- 
graph: 

"  As  soon  as  any  function  is  set  down  as  deficient 
at  its  due  time  of  development,  the  cause  must  be 
sought  and  combated ;  if  external,  removed ;  if  seated 
in  the  nervous  apparatus,  counteracted  by  the  earliest 
course  of  training  and  hygienic  measures.  The  arm 
of  the  mother  becomes  a  swing  or  a  supporter;  her 
hand  a  monitor  or  a  compressor;  her  eye  a  stimulant 
or  a  director  of  the  distracted  look;  the  cradle  is 
converted  into  a  class-room  or  gymnasium/'*  It 
must,  however,  be  remembered  that  the  mother,  if 
of  neurotic  temperament,  is  not  the  best  person  to 
conduct*  these  infantile  exercises.  A  judicious  nurse, 
sympathetic,  but  not  emotional,  will  have  a  better 
chance  of  success. 

(A)  GENERAL. — Proper  Feeding  is  of  the  first  im- 
portance. An  emotional  mother  should  not,  as  a  rule, 
suckle  her  child.  In  her  place  a  healthy,  strong-minded 
wet-nurse  should  be  employed,  or  judicious  artificial 
feeding  used.  The  risk  of  scurvy-rickets  from  the 
exclusive  use  of  preserved  foods  (as  demonstrated  by 
Sir  Thomas  Barlow  in  his  1894  Bradshaw  Lecture) 
must  not  be  forgotten,  and  fresh  milk  in  some  form 
should  come  into  the  dietary.  Frequently  we  find 
that  infants  who  must  be  fed  artificially  do  best  with 
fresh  cows'  milk,  unsterilised,  but  diluted  with  a 
little  water  or  barley-water.  In  the  case  of  infants 
who  give  evidence  of  their  mental  weakness  by  in- 
ability to  suck,  a  spoon  must  be  used,  and  great 

*  Idiocy,  p.  88.     New  York,  1866. 


172      MENTALLY  DEFICIENT  CHILDREN 

patience  exercised.  As  the  child  gets  older,  well- 
boiled  oatmeal  porridge  (par  excellence  the  food  for 
bone  and  brain  building)  should  be  given.  Careful 
attention  must  be  paid  to  the  action  of  the  bowels, 
which  are  apt  to  be  sluggish,  though  sometimes  there 
is  a  tendency  to  mucous  flux.  The  hygiene  of  the 
skin  must  be  studied,  and  frequent  baths,  with  fric- 
tion, are  beneficial  in  promoting  cutaneous  exhalation, 
otherwise  often  offensive,  and  in  aiding  the  sluggish 
circulation.  Muscular  activity  should  be  encouraged, 
and  the  child  frequently  laid  on  the  "kicking-rug,"  and 
encouraged  by  playful  methods  to  exercise  its  limbs. 
Fresh  air  is  absolutely  essential,  and  we  unhesitatingly 
recommend  the  modern  vogue  of  keeping  the  baby 
out  of  doors  for  a  considerable  part  of  every  day, 
asleep  and  awake,  care,  of  course,  being  taken  to  see 
that  he  is  properly  protected  from  the  weather,  and 
kept  warm  by  hot-water  bottles,  if  necessary. 

Cleanly  habits  must  be  promoted  by  every  possible 
means.  It  is  a  mistake  to  condemn  the  defective 
infant  to  perpetual  swaddling-clothes.  The  aim 
should  be  to  approximate  as  near  as  is  practicable  to 
the  normal  child,  in  costume  as  well  as  other  matters. 
We  have  seen  children  of  six  swathed  in  napkins 
round  their  loins,  reeking  with  offensive  filth,  to  the 
great  discomfort  of  all  concerned,  whereas  methodical 
personal  attention  would  have  obviated  the  need  of 
such  expedients.  Regularity  in  the  relief  of  the 
bowels  and  the  bladder  should  be  inculcated  early, 
and,  of  course,  more  frequent  facilities  are  required 
than  for  ordinary  children ;  but,  except  in  the  case  of 
degraded  idiots,  there  is  every  prospect  of  cleanliness 
being  attained  by  perseverance.  The  practice  of 
wetting  the  bed  is  a  common  one  with  weak-minded 
people  of  all  degrees,  and  sometimes  there  is  a  physical 


TREA  TMENT— GENERA  L  1 73 

weakness  of  the  urinary  apparatus,  which  may  be 
corrected  by  appropriate  treatment.  More  frequently, 
however,  these  laches  are  the  result  of  inattention, 
and  then  moral  methods,  in  the  way  of  simple 
rewards  and  punishments,  may  be  tried.  One  very 
simple  remedy,  partaking  both  of  the  physical  and 
moral,  is  the  restriction  of  the  amount  of  fluid 
imbibed  towards  bed-time,  and  mentally  feeble  chil- 
dren are  often  "  thirsty  souls/'  Raising  the  foot  of 
the  bed,  and  ensuring  that  the  child  does  not  sleep 
on  his  back,  are  two  other  household  remedies^  often 
efficacious.  We  do  not  approve  of  india-rubber 
urinals,  and  other  mechanical  arrangements,  which 
only  tend  to  perpetuate  bad  habits,  any  more  than 
we  do  of  the  ingenious  (?)  method  proposed  by  an 
Idiot  Asylum  Superintendent  of  keeping  his  beds 
clean  by  the  nightly  administration  of  enemata  to 
all  dirty  patients.  Belladonna  is  the  drug  on  which 
most  reliance  is  placed;  sometimes  small  doses  of 
thyroid  are  beneficial. 

If  the  child  has  a  tendency  to  dribble,  efforts  must 
be  made  to  strengthen  the  muscles  of  the  lips.  Such 
exercises  as  holding  a  pencil  transversely  between 
the  lips  for  a  given  time,  and  blowing  whistles  and 
trumpets,  may  be  useful  for  this  purpose. 

The  clothing  requires  consideration.  As  with 
other  children,  it  should  be  warm,  yet  light,  and 
free  from  constricting  bands.  Woollen  under- 
garments should  be  worn  in  all  cases  where  this 
is  practicable,  but  with  wet  cases  there  may  be 
a  difficulty  as  regards  the  nether  garments,  and 
where  frequent  washing  is  necessary,  swansdown  or 
some  such  material  may  be  used.  Jaeger's  natural 
wool  in  winter,  and  cellular  cloth  (the  so-called 
"  Aertex  ")  in  summer,  form  appropriate  gradations 


174      MENTALLY  DEFICIENT  CHILDREN 

as  to  warmth.  With  regard  to  the  cut  of  the  clothes, 
this  should  conform  as  nearly  as  may  be  to  the 
ordinary  fashion.  It  is  wrong  to  accentuate  per- 
sonal peculiarities  by  peculiar  clothing.  There  is  no 
good  reason  why  boys  of  eight  or  more  should  con- 
tinue to  be  dressed  like  girls,  when  kilted  costumes 
or  sailor  suits  would  be  quite  as  convenient,  and, 
moreover,  promote  a  sense  of  self-respect.  Weak- 
minded  children  are  often  not  devoid  of  all  pride  of 
appearance ;  this,  judiciously  cultivated,  may  be 
made  a  powerful  level  in  the  upraising  of  good  habits. 
We  have  known  a  case  in  which  a  tendency  to 
destroy  clothing  has  been  overcome,  not  by  attiring 
the  child  in  sackcloth,  but  by  providing  for  her  a 
pretty  costume. 

Appropriate  exercise  occupies  an  important  place 
in  the  general  management.  From  the  first,  plenty 
of  pure  outdoor  air  is  essential  to  the  child  whose 
brain  activity  is  diminished  by  the  imperfect  aeration 
of  its  blood;  and  as  time  goes  on,  such  muscular 
exercise  as  it  is  capable  of  should  by  every  method 
be  promoted.  From  a  false  sense  of  shame  the 
deficient  member  of  the  family  is  too  often  carefully 
concealed  from  the  public  gaze;  when  this  entails, 
as  we  have  known  to  occur,  the  segregation  of  the  poor 
child  to  the  limited  area  of  its  nursery,  or  at  most  to 
the  seclusion  of  its  "  own  back- yard/'  it  is  a  question 
whether  the  Society  for  the  Prevention  of  Cruelty 
to  Children  might  not  advantageously  intervene. 
Teaching  to  walk  will,  of  course,  be  a  more  tedious 
process  than  with  ordinary  children,  but  the  faith 
which  works  by  love  will  accomplish  miracles, 
whereas  neglect  will  too  often  entail  permanent  dis- 
ability. Contractures  of  limbs,  consequent  on  bad 
postures  allowed  to  become  permanent,  are  sometimes 


PLATE  XVIII. 


J.  L.   f "  DIOGENES  "). 
(R.A.A.) 


To  face  page  175. 


TREA  TMENT— GENERA  L  1 75 

met  with  in  the  mentally  feeble ;  and  we  have  a  vivid 
recollection  of  a  poor  boy  of  twelve  who,  having 
spent  his  childhood,  like  a  modern  Diogenes,*  in  a 
tub  (a  sugar-hogshead),  was  brought  to  us  with  his 
legs  so  hopelessly  deformed  by  his  constrained  posture 
that  he  was  a  complete  cripple,  though  we  afterwards 
succeeded  in  getting  him  to  use  a  tricycle  specially 
built  for  him. 

But  we  must  not  linger  on  methods  of  exercise, 
which  will  be  treated  later;  nor  can  we  now  enforce 
the  importance  of  moral  training  from  the  earliest 
age  in  the  formation  of  good  habits,  for  this  forms 
the  subject  of  a  future  chapter.  It  must  suffice  to 
say  that  early  home  influences  are  specially  potent 
for  good  or  harm  in  the  case  of  the  mentally  deficient 
child,  and  it  behoves  the  parents  of  such  to  promptly 
obtain  expert  advice  on  the  subject,  as  well  as  the 
aid  of  a  well-qualified  and  intelligent  nurse  or  nursery- 
governess. 

The  late  J.  Langdon-Down,  in  his  Lettsomian 
Lecturesf  for  1887,  laid  stress  on  the  prevalence  of 
"  morbid  sexual  erethism "  in  mentally  deficient 
children  of  tender  years,  due  oftentimes  to  the 
nefarious  practices  of  an  unworthy  nurse.  Whilst, 
happily,  in  our  own  experience  this  condition  has 
not  proved  as  frequent  as  some  allege,  yet  the  con- 
tingency must  be  borne  in  mind,  and  proper  precau- 
tions taken. 

The  approach  of  puberty  is  of  necessity  an  anxious 
epoch  as  regards  domestic  management,  and  too 
much  care  cannot  be  exercised  by  those  in  charge  of 
"feeble-minded  youths"  (of  both  sexes)  to  guard 
against  abuses  of  the  animal  instincts  then  awakened. 

*  See  Plate  XVIII. 

|  Mental  Affections  in  Childhood  and  Youth,  p.  47 


176      MENTALLY  DEFICIENT  CHILDREN 

Employment  in  the  open  air  at  this  period  will  be 
special  value;  for  obvious  reasons,  sending  to  bed  ir 
the  day-time  as  a  punishment  must  not  be  thought  of 

(B)  We  now  pass  to  methods  in  the  treatment  of  the 
mentally  deficient  child,  which  we  may  more  especially 
designate  MEDICAL.  It  has  been  already  stated  that 
such  children  are  as  a  rule  physically  as  well 
mentally  deficient.  At  any  rate,  they  are  feeble 
body  as  well  as  in  mind;  sometimes  (as  was  said 
one  of  our  Kings)  "  not  only  weak  in  the  head,  but 
also  weak  in  the  understandings."  The  limbs,  as  wel 
as  the  brain,  are  imperfectly  developed,  and,  ot 
course,  nervous  defects  and  disorders  are  frequently 
met  with.  There  is  in  many  cases,  moreover, 
tendency  to  malnutrition,  and  a  want  of  tone  whicl: 
renders  its  subjects  specially  liable  to  the  inroads 
infectious  disease,  and  to  parasitic  skin  affections. 

We  have  already  stated  that  a  phthisical  family 
history  is  common  with  mentally  deficient  children 
We  shall  not,  therefore,  be  surprised  to  find  in  the 
a  marked  predisposition  to  tubercular  disease,  some 
times  affecting  the  joints,  more  often  the  lungs,  and 
occasionally — though  perhaps  less  frequently  tt 
would  be  anticipated — the  meninges  of  the  brair 
Such  causes  of  death  formerly  loomed  large  in  the 
principal  English  institutions  for  defectives,  account 
ing  for  at  least  50  per  cent,  of  the  mortality  of  the 
inmates.  Improved  sanitary  conditions,  better  ven- 
tilation and  heating,  and,  above  all,  an  increas 
open-air  regime,  have  brought  about  a  striking 
diminution  in  the  tubercular  death-rate.  Thus,  in 
his  Annual  Report  on  the  Royal  Eastern  Counties 
Institution  for  1912,  Dr.  Douglas  Turner  states  that 
during  the  seven  preceding  years  it  had  averaged  only 
9-2  per  thousand,  less  by  35  per  thousand  than  the 


TREA  TMENT— MEDICAL  177 


average  prevailing  previous  to  that  period.  It  must, 
however,  be  borne  in  mind  that  mental  defectives 
as  a  class  are  unusually  prone  to  the  infection  of 
tubercle.  In  all  cases,  therefore,  it  behoves  the 
medical  attendant  to  watch  for,  and  guard  against, 
the  incipient  symptoms  of  tubercular  disease,  fortify-l 
ing  the  constitution  against  it  by  open  air,  hygienic 
surroundings,  judicious  feeding,  including  a  suffi- 
ciency of  carbonaceous  elements,  and  the  adminis-'^ 
tration  of  such  medicaments  as  cod-liver  oil,  malt 
extract,  and  Parrish's  chemical  food.  \  Children  of  the 
"  Mongol "  type  are  specially  liable  to  break  down 
from  exposure,  and  in  cold  weather  are  apt  to  suffer- 
not  only  from  chills  externally,  but  from  internal 
congestions  favourable  to  the  development  of  tubercle! 
bacilli.  Tubercular  affections  of  glands,  eyelids,  \ 
bones,  and  joints,  frequently  occur. s  The  treatment 
of  these  will  be  considered  under  the  head  of  Surgical. 
Mucous  diarrhoea  is  a  frequent  ailment,  especially 
with  "  Mongols/'  and  calls  for  care  as  regards  feeding, 
and  for  suitable  medication.  We  have  found  much 

1  benefit  in  these  cases  from  the  administration  of  a 
mucilaginous  mixture  of  castor-oil,  with  the  addition 

;  of  minute  doses  of  opium.  Sometimes  small  and  re- 
peated doses  of  grey  powder  or  calomel  are  of  service. 
Astringents,  pure  and  simple,  given  too  early,  are 
apt  to  add  to  the  intestinal  irritation. 

Epilepsy  has  been  stated  to  occur  in  at  least  25  per 
cent,  of  all  weak-minded  children.  Its  dietetic  and 
medical  treatment  is,  consequently,  of  much  im- 
portance in  the  amelioration  of  the  mental  affections 
of  youth,  which  it  sometimes  causes,  and  always  tends 
to  aggravate.  Our  experience  leads  us  to  lay  stress 
upon  the  importance  of  a  carefully  regulated  diet 
free  from  stimulating  elements,  milk  food  being  a 

12 


178     MENTALLY  DEFICIENT  CHILDREN 

leading  ingredient,  with  a  restricted  allowance  ot 
meat.  All  food  must  be  thoroughly  cooked  anc 
well  masticated.  To  insure  the  latter  condition, 
services  of  a  dentist  are  often  required.  Spratling* 
condemns  the  eating  of  pastry  or  cake  in  any  form, 
also  of  small  fruits  containing  hard  seeds.  All  ale 
holic  drinks  must  be  avoided,  and  only  cocoa  or  weal 
tea  and  coffee  be  given.  Cucumber  and  cabbage 
should  be  avoided.  When  bromide  is  administere 
table  salt  should  be  abstained  from. 

As  regards  drug  treatment,  while  there  is  no  ques 
tion  of  the  value  of  bromides  in  certain  cases,  there 
is  considerable  difference  of  opinion  as  to  whether 
they  should  be  adopted  as  a  routine  treatment  for  ; 
and  sundry,  and  also  as  to  the  amount  of  the  dose. 
Dr.  McCallum,  f  the  Medical  Officer  of  the  School  for 
Epileptic  Boys  at  Starnthwaite,  in  Westmorland, 
an  enthusiastic  advocate  of  the  routine  administra- 
tion of  bromide,  and  often  in  large  doses.  He  gives 
20  grains  night  and^  morning,  and  increases  bj 
10  grains  per  day  as  long  as  fits  occur.  If  necessary, 
he  administers  100  or  even  300  grains  daily,  but 
80  grains  is  the  average.  His  experience  is  that 
boys  take  80  or  100  grains  quite  well,  but  that  wit! 
150  grains  or  more  equilibrium  is  interfered  with,  and 
the  patient  must  be  kept  in  bed.  He  has  excellent 
results  to  show  in  support  of  his  system.  At  Ling- 
field,  J  where  most  of  the  children  are  said  to  have 
more  or  less  mental  defect,  bromide  is  given  in  selectee 
cases,  and  pushed  if  necessary.  The  results  in  thes 
cases  are  very  good,  and  in  almost  every  instance  the 

*  Epilepsy  and  its   Treatment,   by    William  P.   Spratling. 
Philadelphia,  N.Y.     London:  W.  B.  Saunders  and  Co.,  1904. 
f  British  Medical  Journal,  March  14,  1908. 
J  Ibid.t  June  i,  1907. 


TtlEA  TMENT—MEblCA  L  i  79 

child's  work  and  mental  capacity  has  improved.  The 
statistics  quoted  by  Dr.  Aldren  Turner  in  his  book  on 
epilepsy  show  that  50  per  cent,  of  the  cases  treated 
with  bromide  derive  benefit — facts  which,  as  he  points 
out,  go  to  disprove  Dr.  Spratling's  contention  that, 
if  recovery  takes  place  under  the  use  of  the  bromides, 
it  is  in  spite  of,  and  not  on  account  of,  the  drug.  In 
our  opinion,  the  idiosyncrasies  of  each  case  must  be 
studied,  and  while  some  are  beneficially  influenced  by 
bromides,  others  will  do  best  with  borax  or  a  mixture 
of  the  two.  Dr.  E.  C.  Seguin,  of  New  York,  advo- 
cated the  addition  of  a  small  dose  of  chloral.  It  is 
well  to  remember  the  value  sometimes  of  a  combina- 
tion of  the  bromides.  Care,  of  course,  must  be  taken 
that  depressing  effects  are  not  produced.  If  acne 
occurs,  the  temporary  administration  of  arsenic  is 
useful.  Bromide  rashes  are,  however,  relatively  un- 
common in  persons  of  cleanly  habits,  and  Dr. 
McCallum,  of  Starnthwaite,  says  there  need  be  no 
fear  of  a  rash  if  the  best  English  bromide  is  used. 
He  says  that  the  only  treatment  ever  necessary,  if 
it  does  occur,  is  a  soothing  ointment,  and  that  the 
bromide  can  be  continued.  Strontium  bromide  has 
been  recommended  as  preferable  to  the  potassium 
salt,  but  Dr.  Aldren  Turner  states  that  he  has  not 
found  it  more  valuable  than  the  other  bromides. 
He  refers  to  favourable  results  obtained  by  the  use 
of  the  combination  of  potassium  bromide,  arseniate 
of  antimony,  and  picrotoxin,  known  as  Gelineau's 
Dragees.  Among  other  preparations  of  bromide, 
we  have  had  favourable  experience  of  bromipin 
(bromide  and  sesame-oil).  It  is  quite  as  efficacious 
as  the  ordinary  bromides,  and  is  now  made  in  special 
tablets,  which  children  take  readily.  It  is  also  useful 
for  excitable  children.  Bromipin  can  be  given  hypo- 


i8o        MENTALLY  DEFICIENT  CHILDREN 


dermically  in  the  status  epilepticus  without  fear  of 
abscess,  and  is  not  a  gastro-intestinal  irritant,  the 
sesame -oil  with  which  it  is  made  up  being  a  simple 
emollient.  The  late  Dr.  Andriezen*  spoke  highly  of 
a  combination  of  antipyrin  (5  grains)  with  ammonium 
bromide  (15  grains)  as  "  promoting  a  degree  of 
mental  brightness. "  In  debilitated  cases,  the  glycero- 
phosphates  form  a  valuable  combination  with  the 
bromides.  If  there  be  a  syphilitic  element  in  the 
causation  of  the  epilepsy,  bichloride  of  mercury,  com- 
bined with  bark,  may  be  of  benefit,  or  the  ordinary 
grey  powder,  or  else  treatment  by  inunction.  Sal- 
varsan  has  been  satisfactorily  employed,  but  in  the 
light  of  our  present  experience  should  be  reserved 
for  those  grave  cases  showing  symptoms  at  birth. 
Its  injection  is  difficult  and  dangerous  in  babies;  it 
should  be  remembered  that  they  are  very  liable 
to  choroiditis,  and  as  a  rule  respond  well  to 
mercury. 

As  regards  organotherapy  it  is  disappointing,  in 
view  of  the  frequent  association  of  glandular  with 
mental  defect,  that  so  far  little  benefit  has  followed 
the  use  of  organic  extracts,  beyond  that  of  thyroid 
in  cretinism.  Recently  good  results  have  been  ob- 
tained with  pituitary  extract  in  cases  in  which  the 
hypophysis  cerebri  has  been  involved  when  the  base 
of  the  skull  has  been  fractured,  or  has  had  its 
function  impaired  by  other  pathological  changes  in 
the  Sella  Turcica.  The  pathology  of  these  cases  and 
the  method  of  recognising  them  by  an  X-ray  ex- 
amination have  been  described  in  Chapter  IV. 

Serotherapy,  or  the  treatment  of  epilepsy  by  in- 
jections of  blood-serum  from  another  epileptic,  as 
introduced  by  Ceni,  has  recently  been  carried  out  by 

*  British  Medical  Journal,  September  16,  1899,  p.  713. 


TREA  TMENT— MEDICAL  181 

Dr.  Alfred  Gordon,*  of  Philadelphia,  in  a  small  group 
of  cases,  with  beneficial  results,  as  described  in 
Chapter  IV.  The  auto-intoxication  theory  of  the 
origin  of  epileptic  seizures  has  not  been  proved,  but 
may  hold  good  in  a  small  minority  of  cases,  and,  at 
any  rate,  often  aggravates  the  condition,  even  when 
the  real  cause  is  to  be  sought  elsewhere.  Attention 
to  the  eliminating  channels  is,  therefore,  essential. 
The  periodical  administration  of  calomel  and  other 
intestinal  antiseptics  is  often  beneficial.  It  is  to  this 
view  of  the  origin  of  epilepsy  that  the  drugs  bromaline 
(bromine  and  formaldehyde  derivatives)  and  bromo- 
carpine  (bromine  and  pilocarpine)  owe  their  intro- 
duction. 

In  petit  mal,  which  is,  perhaps,  more  often  asso- 
ciated with  mental  enfeeblement  than  grand  mal,  and 
has  a  less  hopeful  prognosis,  E.  C.  Seguin  speaks  well 
of  "  combining  with  a  very  moderate  bromide  course 
the  free  use  of  strychnine  and  atropine  or  bella- 
donna, "f 

More  important  than  drug  treatment  is  what  one 
may  call  the  "  outdoor  occupation  cure."  The  ex- 
perience of  the  Royal  Albert  Asylum,  and  more 
recently  of  the  various  epileptic  colonies,  is  quite 
emphatic  in  this  direction.  Mere  loafing  in  the  open 
air  is  to  very  little  purpose.  Occupation  is  the  pre- 
dominant factor  for  good. 

The  most  striking  advance  in  the  medical  treat- 
ment of  mental  in  conjunction  with  bodily  defect  is 
that  of  sporadic  cretinism.  Up  to  the  year  1890, 
this  was  thought  to  be  a  hopeless  form  of  idiocy; 

*  Alfred  Gordon,  M.D.,  New  York  Medical  Journal,  1914, 
xcix.  10. 

f  "  Treatment  and  Management  of  Neuroses/'  New  York 
Medical  Journal,  May,  1890,  p.  31. 


1 82       MENTALLY  DEFICIENT  CHILDREN 

but  the  experimental  researches  of  Victor  Horsley 
and  others  encouraged  the  view  that  benefit  might 
be  derived  from  the  implantation  of  the  thyroid 
gland  of  the  sheep  in  such  cases.  Subsequently  it 
was  found  that  the  injection  of  thyroid  juice  was  of 
equal  efficacy,  and  later  that  the  ingestion  by  the 
mouth  of  the  gland  itself,  or  its  preparations,  was  the 
best  and  most  efficient  mode  of  treatment.  Thyroid 
grafting — a  method  of  treatment  which  went  out  of 
vogue — has  recently  been  suggested  afresh  by  Sir 
Victor  Horsley  as  the  most  desirable  method,  because 
it  is  permanent  and  avoids  the  continued  administra- 
tion of  thyroid  extract.  His  views  on  this  subject 
will  be  found  in  the  discussion  on  Dr.  McGarrison's 
paper  on  "  Endemic  Cretinism  in  Chitral  and  Gilgit  " 
(published  in  the  Proceedings  of  the  Royal  Society  of 
Medicine,  vol.  ii.,  No.  i,  Medical  Section,  p.  i).  When 
thyroid  extract  is  administered,  mental  awakening 
proceeds  pari  passu  with  physical  development  in  a 
manner  almost  startling.  Those  interested  in  the  sub- 
ject are  referred  to  an  article  by  Dr.  Shuttleworth  in 
Wright's  Medical  Annual  for  1894,  p.  324  et  seq.  The 
adjustment  and  regulation  of  the  dose  appropriate  to 
each  case,  so  as  to  avoid  stomach  irritation,  excessive 
temperature,  and  undue  emaciation,  are  the  points 
calling  for  attention.  So  far  as  we  can  judge  from 
present  experience,  this  treatment  (though  in  modified 
doses)  must  be  permanent.  Starting  in  children  (ac- 
cording to  age)  with  one  or  more  2i-grain  tabloids 
daily,  the  dose  may  be  cautiously  increased  up  to 
six  tabloids,  and  when  improvement  has  been  achieved 
one  or  two  5-grain  tabloids  daily  will  usually  suffice 
to  maintain  it.  The  annexed  Plate  XIX.,  for  which 
we  are  indebted  to  the  courtesy  of  Drs.  Railton  and 
Telford-Smith,  shows  the  condition  before  and  after 


TREA  TMENT—S  URGICA  L  1 83 

treatment  of  two  brothers,  one  of  whom  was  formerly 
under  Dr.  Shuttleworth's  care  at  Lancaster,  while 
Plate  XX.  depicts  their  ultimate  condition. 

The  majority  of  mentally  deficient  children  being 
of  feeble  constitution,  the  prognosis  of  the  exanthe- 
mata, and  of  acute  disease  generally,  must  be  guarded, 
while  depressing  treatment  is  inadmissible.  Cerebral 
complications  are  frequent,  and  convulsions  not  un- 
common. Troublesome  sequelae  affecting  mucous 
membranes  (in  the  eyelids  and  elsewhere)  are  apt  to 
occur  after  measles,  which,  in  our  experience,  is  a 
disease  almost  as  formidable  as  scarlatina  with  defec- 
tives. The  irritability  of  mucous  membranes  is  at 
all  times  a  source  of  trouble  with  mentally  deficient 
children,  andcatarrhal  discharges  from  the  eyes,  nose, 
and  ears  have  to  be  treated  with  astringent  lotions. 
Spongy  gums  are  frequently  found,  especially  when 
the  hygiene  of  the  mouth  is  not  attended  to,  and 
chlorate  of  potash  washes  are  useful  in  these  cases. 
Aphthous  patches  and  parasitic  diseases  of  the  skin 
must  be  treated  by  appropriate  remedies.  Curious 
skin  affections  of  neurotic  origin  are  sometimes  met 
with  in  cases  of  mental  feebleness,  such  as  that 
described  by  Dr.  Pringle  and  others  under  the  name 
of  "  Adenoma  sebaceum,"*  and  now  recognised,  as 
we  have  described  in  Chapter  IV.,  as  part  of  a  clinical 
entity  designated  "  tuberous  sclerosis  "  or  "  epiloia." 

(C)  A  few  remarks  as  to  SURGICAL  treatment  in 
relation  to  mentally  deficient  children  must  close  this 
chapter.  The  contractures  of  limbs  may  sometimes 
be  remedied  by  tenotomy,  but  the  deficiency  of 
reparative  power,  and  the  difficulty  found — -at  any 
rate,  with  low-grade  cases. — in  keeping  appliances 
in  position  and  free  from  filth,  must  be  borne  in 

*  British  Journal  of  Dermatology,  January,  1890. 


1 84       MENTALLY  DEFICIENT  CHILDREN 


mind  before  undertaking  a  surgical  operation.  We 
cannot,  therefore,  give  mentally  deficient  childre 
the  full  benefit  of  all  modern  surgery  has  achieved  in 
the  treatment  of  paralysis,  especially  as,  to  ensure 
success,  the  after-treatment  must  be  prolonged. 
Indeed,  Mr.  Robert  Jones,*  of  Liverpool,  has  placed 
many  of  these  unfortunate  children  "  in  a  group  out- 
side remedial  art."  For  the  relief  of  constitutional 
disturbance,  however,  such  as  that  caused  by  bone 
or  joint  disease  in  tubercular  cases,  operative  inter- 
ference is  justifiable,  and  is  generally  successful.  We 
have  repeatedly  seen  considerable  benefit  to  mental 
activity  from  the  clearing  away  of  post-nasal  adenoid 
vegetations  in  feeble-minded  children. 

About  1890  the  operation  of  cranieetomy — i.e.,  the 
cutting  of  strips  of  bone  from  the  cranium — was 
recommended  in  cases  of  microcephalus.  This  prac- 
tice has,  however,  been  abandoned,  owing  to  the 
disappointing  results,  and  the  knowledge  that  the 
small  skull  is  simply  moulded  to  the  brain,  the 
development  of  which  has  been  arrested  at  the  fifth 
month  of  intra-uterine  life,  f  When  signs  of  pressure 
are  seen,  however,  as  in  oxycephaly,  and  in  the 
rare  cases  in  which  there  is  a  history  of  prematurely 
ossified  fontanelles,  operative  interference  may  be 
justifiable.  In  Chapter  IV.  we  have  explained  the 
advantage  of  draining  the  subarachnoid  cisterns  in 

*  On  Certain  Principles  and  Methods  in  the  Surgical  Treat- 
ment of  the  Paralysis  of  Children,  by  Robert  Jones,  1902. 

t  See  article  by  Dr.  Shuttleworth,  Medical  Annual,  1895, 
p.  327.  Dr.  Telford-Smith  has  described  and  illustrated  in 
the  American  Journal  of  Psycho- A  sthenics  for  June,  1897, 
the  cases  of  two  microcephalic  boys  whom  he  had  the  oppor- 
tunity of  closely  observing  during  four  years  after  cranieetomy 
had  been  performed,  his  conclusion  being  that  in  the  light 
of  results  the  operation  is  unjustifiable. 


TREATMENT  OF  MENTALLY  DEFICIENT     185 


cases  of  status  epilepticus  due  to  a  localised  meningitis 
serosa  externa.  Beneficial  results  have  been  fre- 
quently obtained  by  cranial  operations  in  cases 
of  mental  deficiency  associated  with  traumatism, 
epilepsy,  and  paralysis;  in  such  cases  surgery 
should  not  be  deferred  until  after  the  establish- 
ment of  serious  atrophic  changes  and  degenera- 
tions. The  diagnosis  of  abnormal  cranial  condi- 
tions, which  may  give  rise  to  prejudicial  irritation 
of  subjacent  tissues,  is  facilitated  by  the  progress 
of  radiography,  skiagrams  demonstrating  with  fair 
clearness  the  cranial  outlines  being  now  available. 


CHAPTER  IX 
EDUCATIONAL  TRAINING 

WE  now  pass  to  the  consideration  of  means  which, 
as  distinguished  from  general  treatment,  we  maj 
designate  Educational.  Under  this  term  we  include 
all  those  methodical  and  specific  exercises,  whether 
physical  or  mental,  which  naturally  fall  into  the  school 
routine,  and  need  for  their  direction  a  skilled  teacher, 
acting  in  concert  with  the  physician.  The  kind  and 
amount  of  educational  exercise  appropriate  to  a  par- 
ticular case  of  mental  deficiency  or  feebleness  should 
indeed  be  prescribed  by  the  latter,  and  consequently 
a  cursory  sketch  of  the  teaching  technique  adapted 
to  characteristic  varieties  may  not  be  out  of  place  in 
what  aspires  to  be  essentially  a  medical  work.  As  a 
matter  of  convenience,  industrial  and  moral  training, 
though  forming  integral  portions  of  the  educational 
system,  will  be  considered  in  subsequent  chapters. 

In  dividing  educational  means  into  (a)  physical 
(those  more  particularly  addressed  to  the  body),  and 
(b)  mental  (those  more  particularly  addressed  to  the 
intelligence),  we  must  bear  in  mind  that  the  two  are 
not  independent  of  each  other,  and  that,  with  regard 
to  mentally  deficient  children  especially,  "  the  physi- 
ological education  of  the  senses  must  precede  the 
psychical  education  of  the  mind."*  We  may  add 
that  the  training  of  the  muscular  system  to  ready 

*  Seguin,  New  Facts,  etc.,  p.  41.     New  York,  1870. 
1 86 


EDUCATIONAL  TRAINING  187 

and  regulated  response  is  merely  an  extension  of  sen- 
sorial  training;  and  both  these  processes  naturally 
precede,  and  prepare  the  way  for,  more  purely  intellec- 
tual training.  It  has  been  well  remarked  by  Froebel 
that,  "  in  primary  education,  the  Doing,  the  Thing 
Done,  the  Teaching  and  the  Learning,  must,  in  every 
case,  rest  on  actual  fact  and  on  real  existence,  so  that 
the  mental  intelligence,  incessantly  striving  upwards 
in  single  things,  as  in  its  general  career,  may  thereby 
expand  and  develop  the  life-giving  creative  powers 
of  the  pupils,  according  to  the  measure  of  their 
strength  and  ability,  their  talents  and  desires."* 
The  mentally  feeble  child  is  specially  incapable  of 
comprehending  abstractions:  all  instruction,  there- 
fore, must  be  presented  to  it  in  a  concrete  form,  which 
it  can*  not  only  see,  but,  when  possible,  grasp  in  the 
hand  as  well  as  in  the  mind.  Many  of  the  "  games  " 
and  "  occupations  "  of  the  kindergarten  are  conse- 
quently of  service,  but  whereas  the  normal  child  exer- 
cises its  own  spontaneous  activity  through  these 
occupations,  those  who  are  mentally  deficient,  especi- 
ally those  of  the  apathetic  type,  have  to  be  stimu- 
lated to  action  by  the  force  of  imitation.  Our  system 
of  education,  then,  starts  on  physiological  lines,  first 
addressing  itself  to  the  culture  of  the  external  senses, 
then  to  the  co-ordination  of  muscular  movement,  and 
finally  to  the  promotion,  by  imitative  and  other 
exercises,  both  of  the  manual  and  mental  activities. 

In  thus  laying  down  these  general  principles  of 
procedure,  it  must  not  be  imagined  that  all  cases  can 
be  treated  in  the  same  way.  On  the  contrary,  it  is 
essential  to  success  that  the  teacher  should  study  the 
individual  peculiarities  of  each  case,  and  adapt  the 

*  Froebel' s  Letters  on  the  Kindergarten.  Swan  Sonnen- 
schein  and  Co.,  1891. 


i88       MENTALLY  DEFICIENT  CHILDREN 

educational  methods  employed  to  those  peculiaritie 
Mentally  abnormal  children  may  be  broadly  divide 
into  two  main  groups:  (i)  those  who  are  dull  and 
apathetic;  (2)  those  whose  nervous  and  mental  action 
is  irregular.  It  is  obvious  that  the  rousing,  stimu- 
lating regime  suitable  for  the  former  is  not  that  most 
appropriate  to  the  latter,  in  whom  the  inhibitory  and 
co-ordinating  functions  require  to  be  strengthene 
by  exercise. 

As  extreme  examples  of  the  first  group  we  ma} 
instance  the  "  impassive,  low-grade  idiot,  whos 
education  begins  with  a  bombardment  of  bean-bags. 
Such  a  child  is  so  inert  as  not  at  first  to  put  up  its 
hands  to  protect  its  face  from  the  bean-bag  thrown  at 
it  by  the  teacher;  gradually,  however,  the  instinct 
of  self-preservation  asserts  itself  so  far  as  to  ward  of 
the  missile.  The  second  step,  to  catch  the  bag,  anc 
the  third,  to  throw  it  back  to  the  teacher,  mark 
successive  steps  of  improving  mental  activity;  and 
from  these  progress  is  made  in  the  direction  of  simple 
drill,  aided  by  music/'*  The  bean-bags  referred  to 
are  about  5  inches  square,  .made  of  bright-coloured 
flannel,  and  loosely  filled  with  beans  or  rice,  so  that 
their  impact  is  not  hurtful.  The  same  sort  of  exercise, 
varied  by  aiming  the  bags  so  as  to  pass  through  round 
or  square  holes  in  a  board,  or  into  the  mouth  of  a 
grotesque  figure,  is  exceUent  for  promoting  alertness 
of  the  eye  and  hand,  as  well  as  concentrating  atten- 
tion, in  higher-grade  children. 

Amongst  children  of  the  second  group  we  include 
those  with  evidences  of  an  over-mobile  nervous 
system,  or  with  uniform  repetitive  movements,  such 

*  See  paper  by  Shuttleworth,  "On  Points  Connected  with 
the  Education  of  Feeble-minded  Children,"  British  Medical 
Journal,  September  8,  1894. 


EDUCATIONAL  TRAINING  189 


as  those  designated  athetosis.  The  golden  rule  in 
these  cases  is — try  to  substitute,  in  place  of  purpose- 
less, irregular  movements,  motor  exercises  with  a 
definite  purpose,  and  calling  for  will-power.  In  this 
way  inability  to  fix  the  attention  (aprosexia,  as  it  has 
been  called)  is  gradually  overcome,  and  the  moral 
satisfaction  resulting  from  "  something  attempted, 
something  done,"  encourages  to  fresh  efforts.  In 
cases  where  nervous  irritability  is  so  great  as  to  give 
rise  to  destructive  tendencies,  the  irregular  energy 


FIG.  4. — PEG-BOARD. 

should  be  turned  into  constructive  channels;  thus  a 
child  of  this  temperament  may  be  coaxed  to  build  up 
wooden  bricks  into  some  definite  form  for  the  pleasure 
of  knocking  them  down  with  a  crash  !  Gradually  he 
may  be  led  on  to  practise  building  for  its  own  sake. 
The  child  with  incessant  movements  of  his  fingers 
(athetosis)  is  usually  not  greatly  wanting  in  will- 
power, and  it  is  marvellous  how  much  may  be  achieved 
by  appropriate  finger  exercises  (such  as  those  of  the 
peg-board,  see  Fig.  4),  or  the  more  interesting  kinder- 
garten occupation  of  "picture  perforating."  The 


190       MENTALLY  DEFICIENT  CHILDREN 

intelligent  teacher  will  know  how  to  adopt,  and  adapt 
to  the  use  of  the  deficient  child,  the  various  educa- 
tional means  now  in  vogue  in  our  infant  schools.  It 
must,  however,  be  borne  in  mind  that  much  that  the 
normal  child  learns  intuitively  needs  to  be  taught 
specifically  to  the  abnormal.  The  external  senses  are 
often  functionally  inactive,  if  not  structurally  defec- 
tive, and  it  will  be  necessary  to  open  up,  by  a  serie 
of  sensorial  exercises,  these  obstructed  avenues  of 
approach  to  the  central  intelligence.  Then  the  due 
co-ordination  of  muscular  movement  must 
strengthened  and  regulated  by  judicious  drill.  Finally, 
the  general  intelligence  must  be  cultivated  by  inter- 
esting the  child  in  its  surroundings,  and  breaking  dowr 
the  isolation  in  which  the  solitary  idiot,  and  to 
less  extent  the  mentally  feeble  child,  carry  on  their 
existence.  All  this  preliminary  work  of  necessit} 
precedes  instruction  in  the  three  "  R's  "  and  what 
we  are  accustomed  to  regard  as  ordinary  school- 
work.  We  rejoice,  however,  to  find  that  the 
physiological  sequence  we  have  indicated,  and  which 
was  laid  down  by  Seguin  seventy  years  ago  as 
the  educational  mode  for  defective  children  (as  well 
as  for  others),  is  gradually  being  recognised  in  the 
curriculum  of  elementary  schools.  We  do  not  ven- 
ture to  trespass  upon  the  domain  of  pedagogy 
farther  than  to  point  out  the  special  methods  of  in- 
struction indicated  to  meet  the  special  requirements 
of  pupils  who,  by  reason  of  mental  defect  (often 
associated  with  physical),  cannot  "  properly  be  taught 
in  the  ordinary  standards  or  by  ordinary  methods." 

And  first  with  regard  to  sensorial  training,  it  will 
be  convenient  to  consider  separately  the  several 
senses,  though  in  practice  the  training  will  be  of  a 
combined  character. 


EDUCATIONAL  TRAINING  191 

The  tactile  function  is  not  only  the  most  general, 
but  in  some  respects  the  most  important  of  our  senses, 
and  in  the  normal  baby  its  evolution  takes  precedence 
of  the  rest.  Impressions  through  the  eye  and  ear  are 
criticised  through  the  sense  of  touch,  and  this  natural 
development,  so  serviceable  in  the  spontaneous  educa- 
tion of  all  healthy  young  animals,  must  be  imitated 
in  our  endeavours  to  bring  up  towards  the  normal 
standard  the  sensorial  training  of  imperfect  children. 
In  some  cases  we  shall  find  coarse,  insensitive  hands 
which  must  be  drilled  into  sensibility  by  grasping  hard 
and  soft  objects,  and  discriminating  the  resistance 
and  surface  impressions  of  such  varying  substances 
as  polished  marble,  sand-paper,  velvet,  silk,  etc. 
Sensibility  to  heat  and  cold  may  be  gauged  and  culti- 
vated by  the  handling  of  bottles  filled  with  water  of 
varying  degrees  of  temperature.  Such  lessons  will, 
of  course,  form  incidents  of  the  object-lessons  which 
play  so  important  a  part  in  early  education.  In  some 
exceptional  cases  there  is  a  morbid  sensibility  (hyper- 
cesthesia),  which  is  best  counteracted  by  friction 
against  hard  substances,  and  the  employment  of  the 
fingers  in  coarse  work. 

In  order  to  test  and  exercise  tactual  impressions 
apart  from  those  derived  from  the  sense  of  sight, 
Seguin  recommended  that  the  patient  should  be 
placed  in  a  darkened  room.  The  same  object  is  ac- 
complished in  the  Montessori  method  by  blindfolding 
the  child  engaged  in  tactual  discrimination  of  sur- 
faces and  objects.  In  the  case  of  mentally  deficient 
children,  however,  there  is  risk,  as  Dr.  Montessori 
remarks,  that  the  attention  may  be  diverted  to  the 
bandage  itself,  or  that  the  darkened  room  may  pro- 
duce a  condition  of  lethargy  or  disorder  interfering 
with  the  tactual  exercise. 


192       MENTALLY  DEFICIENT  CHILDREN 


The  use  of  the  peg-board  (Fig.  4)  has  already  been 
mentioned  as  serviceable  in  cases  of  athetosis  (spas- 
modic finger  movements) :  it  is  also  valuable  in  culti- 
vating the  tactile  sense.  Similarly,  size  and  form 
boards  (Figs.  5  and  6)  promote  accuracy  not  only  of 
grasping  movements,  but  of  capacity  for  adjustment 
of  insets  to  their  appropriate  cavities;  and  a  pin- 
cushion covered  with  spotted  material,  into  the  spots 
of  which  the  child  sticks  pins,  is  useful  in  exercising 
minute  sensation,  as  well  as  fine  adjustment  of  the 
muscles.  Threading  coloured  beads  and  buttons 
serves  not  only  as  an  exercise  of  tactile  sense,  but, 
as  will  afterwards  be  pointed  out,  of  the  arithmetical 
faculty. 

The  appliances  illustrated  on  pp.  193-194  were  de- 
signed some  sixty  years  ago  by  Seguin  for  use  in 
American  institutions  for  the  feeble-minded,  and  with 
slight  modifications  have  formed  part  of  the  school 
equipment  for  such  institutions  on  both  Continents 
ever  since.  Of  recent  years  similar,  but  more  elaborate, 
appliances  have  been  devised  by  Dr.  Maria  Montessori 
for  use,  not  only  by  defective  children,  but  as  aids 
to  the  auto-education  of  normal  infants,  and  are  on 
sale  under  the  designation  of  the  "  Didactic  Apparatus 
for  use  with  the  Montessori  System  of  Education."* 
The  Dottoressa  acknowledges  in  her  classic  work 
("  The  Montessori  Method  "),  published  in  English  in 
1912,  her  obligations  to  Seguin  and  his  .didactic 
apparatus,  which  she  has  skilfully  systematised  and 
extended.  She  justly  lays  stress  upon  the  spirit- 
uality (or  intelligent  spirit)  in  which  the  apparatus 
needs  to  be  used,  which  is,  indeed,  of  more  importance 
than  the  precise  form  of  its  construction.  It  may 

*  A  list  of  these  appliances  may  be  obtained  from  Messrs. 
Philip  and  Tacey,  Ltd.,  Norwich  Street,  E.G. 


EDUCATIONAL  TRAINING 


193 


perhaps  be  open  to  question  whether  some  of  the 
modifications  introduced  by  her  are  improvements 


FIG.  5. — SIZE-BOARD. 

on  Seguin's  devices.     Thus  the  little  knobs  added 
for  lifting  the   "  geometrical  insets "  detract  from 


FIG.  6.  —  FORM-BOARD. 


their  utility  as  a  grasping  exercise  afforded  by  the 
size  and  form  boards  above  illustrated.  The  grooves 
in  Seguin's  "graduated  rods"  (Fig.  7)  have  ad  van  - 


194       MENTALLY  DEFICIENT  CHILDREN 


FIG.  7. — GRADUATED  WOODEN  RODS. 

2 


(&) 
FIG.  8. — DOMINO-BOARDS. 


(Cl 


tages  as  compared  with  the  "  long  -stair "  of  the 
Montessori  system,  inasmuch  as  the  former  exercise 
the  tactual  as  well  as  the  visual  sense. 


EDUCATIONAL  TRAINING  195 


The  sense  of  sight  comes  next  in  importance  to 
that  of  touch,  as  regards  training.     Ocular  defects 
must,  of  course,  be  treated  by  the  ophthalmic  sur- 
geon, and  in  errors  of  refraction  correcting  glasses 
supplied;  the  teacher's  function  is  to  concentrate  the 
wandering  gaze,  to  specialise  the  vacant  stare  of  the 
defective   pupil.     To    quote   a   quaint    Gallicism   of 
Seguin's,  "  the  main  instrument  in  fixing  the  regard 
is  the  regard  ";  that  is  to  say,  the  vagrant  eye  of  the 
pupil  may  be  brought  to  attention  by  the  fixed  gaze  of 
the  instructor.     Glittering  objects,  such  as  the  sil- 
vered globes  used  for  Christmas-trees,  are  serviceable 
also   for  this  purpose,   especially  with  very  young 
children,  and  the  kaleidoscope  is  an  attractive  toy 
of  distinct  educational  value  for  older  ones.     The  in- 
dependent  movements  of    the   eyeball,   apart   from    I. 
those  of  the  head,  should  be  called  into  play;    the    \ 
training  of  the  ocular  muscles  is  too  often  neglected, 
with  the  result  that  the  child's  lateral  range  of  vision 
is  unduly  restricted.     Discrimination  of  colour  is  a   \ 
later  exercise  of  the  visual  organ;  and  for  this  pur- 
pose discs  of  various  colours  for  the  child  to  match, 
cubes,  the  sides  of  which  are  vari-coloured  and  are 
successively  turned  uppermost,  following  the  lead  of 
the  teacher,  and  a  series  of  cups  and  balls,  to  be  fitted 
together  in  corresponding  colours,   are  useful  aids. 
But  perhaps  more  interesting  to  the  juvenile  mind  is 
the  matching  of  coloured  ribbons  and  articles   of 
clothing,    or    pointing    out    corresponding   hues    in 
coloured   pictures.     Exercises   in   colour   perception 
naturally  lead  to  the  distinguishing  of  colours  by 
name,  but  the  former  take  precedence  in  sensorial 
training.     The  teacher  or  nurse  should  not  therefore 
commence  by  asking  the  child  which  is  red,  blue,  etc., 
but  the  colour  sense  should  be  exercised  by  getting 


196       MENTALLY  DEFICIENT  CHILDREN 

the  child  to  sort  into  separate  heaps  the  severa 
discs  or  pieces  of  coloured  cardboard.  Matching 
coloured  wools,  and  finding  cards  corresponding 
colour  to  the  squares  on  the  colour  chart,  are  other 
useful  exercises.  Forming  pictures  from  picture 
cubes  is  a  more  advanced  form  of  eye  training,  and 
the  use  of  size  and  form  boards  (Figs.  5  and  6),  anc 
of  the  graduated  wooden  rods,  to  be  arranged  in  step- 
like  series  (Fig.  7),  exercises  both  hand  and  eye,  anc 
imparts  ideas  of  form  and  dimension.  Ideas  of  rela- 
tion are  similarly  imparted  by  exercises  with  dominc 
boards  (Fig.  8),  two  of  which  are  placed  (a)  flat,  side 
by  side ;  (b)  at  right  angles  laterally ;  and  (c)  at  right 
angles  end  to  end,  following  the  lead  of  the  teacher. 

Taste  and  smell,  being  essentially  animal  rather 
than  intellectual  senses,  do  not  as  a  rule  require 
much  stimulation  in  the  mentally  deficient  class.  * 
But  discrimination  may  be  exercised  by  offering  tc 
the  pupil  substances  of  similar  appearance,  such 
salt  and  white  sugar,  to  be  distinguished  by  taste; 
ground  coffee  and  snuff,  to  be  distinguished  by 
smell. 

Hearing  is  sometimes  apparently  deficient  when 
the  real  deficiency  is  that  of  attention.  Mentally 
feeble  children  often  hear  perfectly  well,  but  do  not 
take  the  trouble  to  listen;  they  may,  however,  be 
coaxed  to  do  so  by  presenting  to  them  agreeable 
sounds.  Fortunately,  music  has  for  this  class  specia 
charms,  and  a  simple  song  will  often  enlist  attentior 
when  mere  speech  is  disregarded.  Nursery  dittie 

*  Perverted  and  abnormal  states  of  these  senses  are  occa- 
sionally met  with  in  idiots;  we  have  known  one  whose 
peculiar  "  taste  for  literature  "  was  manifested  by  his  "  de- 
vouring his  book,"  cover  and  all;  and  another  who 
tinguished  his  own  and  his  comrades'  clothes  solely  by 
sense  of  smeliv 


TRAINING          197 

are  consequently  not  without  educational  value,  and, 
as  we  shall  see  later,  often  form  stepping-stones  to 
speech.  Tone-deafness  is  sometimes  met  with,  and 
if  low-pitched  sounds  are  not  apprehended,  those 
that  are  more  shrill  (such  as  those  produced  by  the 
whistle)  should  be  tried.  At  a  later  stage  the  discrim- 
ination by  pupils  ol  the  different  quality  of  sounds 
produced  by  different  instruments  is  a  good  exercise. 
Speech  is  a  complex  function,  having  important 
relations  to  auditory  perceptions  on  the  one  side, 
and  on  the  other  being  dependent  upon  the  integrity 
of  nerve  centres  and  tracts,  and  the  due  co-ordination 
of  the  muscular  apparatus  concerned  in  vocalisation 
and  articulation.  More  or  less  imperfection  of  speech 
is  extremely  common  with  mentally  deficient  children, 
and  when  not  the  result  of  want  of  development  or 
lesion  of  the  cerebral  speech-centres,  much  may  be 
done  in  the  way  of  amelioration  by  appropriate 
training.  Excluding  cases  dependent  on  deafness — 
in  which  lip-imitation  methods  are  of  much  value, 
and  the  "  oral  method  "  has  a  literature  of  its  own* — 
we  may  say  that  as  a  rule  such  children  require  to 
be  taught  to  speak  much  as  a  baby  learns  to  speak. 
In  some  cases,  however,  a  course  of  lip  and  tongue 
gymnastics  is  an  essential  preliminary.  The  pupil 
may  be  unable  to  bring  the  lips  together,  to  bring  the 
teeth  together,  or  to  direct  the  tongue  as  required 
for  the  formation  of  a  sound.  In  such  cases  special 
exercises  adapted  to  the  particular  infirmity  are 
requisite.  To  improve  the  power  of  closing  the  lips, 
a  flat  piece  of  boxwood,  an  ordinary  penholder-stick, 
or  a  bone  ring,  may  be  held  by  the  child  between  his 
lips  for  a  few  minutes  at  a  time;  and  this  is  an  exer- 
cise useful  in  repressing  slavering.  Blowing  a  whistle 

*  E.g.,   Lip-Reading,   by   Edward    B.    Nitchie    (London: 
Methuen  and  Co.) . 


ig8      MENTALLY  DEFICIENT  CHILDREN 


is  also  of  service,  and  puffing  into  motion  a  pellet 
paper  or  a  flake  of  cotton-wool  helps  in  the  power 
pursing    up    the    lips    necessary    for    labial   sound 
Opening  and  closing  the  mouth,  so  as  to  bring  the 
teeth  together;  putting  out  the  tongue,  deviating  it 
to  the  right  and  to  the  left,  and  touching  with  it  the 
teeth  of  the  upper  and  the  lower  jaw  respectively 
also  the  roof  of  the  mouth,  are  other  forms  of  or 
exercises   serviceable   in   overcoming   defects  of  cc 
ordination  interfering  with  clear  articulation.     Exer 
cises  in  deep  breathing  are  also  important.* 

In  most  cases,  though  not  in  all,  consonant  sounc 
are  more  readily  acquired  than  vowel  sounds.     Tr. 
normal  infant  starts  its  attempt  at  speech  by  repeatir 
the  simplest  labials  or  linguals:  "  bab-ba,"  "mam- 
ma/'  and  later   "  dad-da, "   are  among  its  earlies 
efforts.     Following  these  lines,  the  child  deficient  in 
speech  should  be  exercised  in  simple  reduplicate 
consonant  sounds,  followed  by  the  open  vowel  a  (ah}. 
A  schedule  of  speaking  exercises  based  on  these  prir 
ciples  was  published  by  the  author  in  an  article  on 
the  "  Educational,  etc.,  Training  of  Idiots  and  Im- 
beciles,"  in   Hack   Tuke's   "  Dictionary  of  Psyche 
logical  Medicine."!     In  this  the  repetitive  phonetic 
(e.g.,  "  mam-ma  ")  is  coupled  with  the  name  of  a  cor 
mon  object  ("  mat,"  "  man  "},  of  a  part  of  the  bod} 
("  mouth  "),  and  of  part  of  dress  ("  muff,"  "  mitten  "), 
beginning  with  the  consonant  sound  (m) ;  and  so  on 
through  the  series  of  labials,  linguals,  labio-dentali 
gutturals,  and  nasals.     There  is  also  af  table  of  vowe 
sounds  and  examples.     But  for  the  present  work  it 
must  suffice  to  say  that  for  mentally  deficient  children 

*  Breathing  Exercises,  by  Duncan  Matheson  Mackay,  M.D. 
(London:  J.  Bale,  Sons  and  Danielsson),  price  id. 

t   Churchill,  1892,  vol.  ii.,  p.  673  (see  Appendix  C,  p,  261) 


EDUCATIONAL  TRAINING  199 

half  the  battle  is  to  sustain  their  interest,  and 
mechanical  exercises  in  speaking,  however  well  de- 
vised, must  be  brightened  up  by  illustration.  The 
naming  of  objects  in  well-chosen  pictures,*  and  of 
the  child's  own  surroundings,  and  the  imitation  of  the 
characteristic  cries  of  animals,  are  some  of  the  best 
means  of  making  a  start  with  speech.  A  child  will 
demur  to  repeat  sounds  read  by  a  teacher  from  a 
table,  though  he  will  cheerfully  respond  to  the  ques- 
tions, "What  does  the  cow  say?"  ("Moo"),  or, 
"  What  does  pussy  say  ?"  ("  Mew  ").  Similarly  he 
will  imitate  the  "  Ba-ba  "  of  the  sheep,  or  the  "  Bow- 
wow "  of  the  dog,  and  thus  learn  both  consonant  and 
vowel  sounds  without  conscious  effort.  Slovenly 
pronunciation,  with  slurring  of  final  consonants, 
especially  if  doubled,  is  a  frequent  failing  with  the 
child  of  inert  temperament,  and  needs  to  be  dealt  with 
by  vigilance  in  reading  and  recitation  exercises. 
Stammering,  and  especially  stuttering,  is  common 
with  those  of  neurotic  type,  and  slow  and  deliberate 
utterance  should  be  encouraged  in  such,  exercises  in 
deep  and  diaphragmatic  breathing  being  an  essential 
preliminary,  with  practice  in  controlling  the  exit  of 
the  breath.  Intonation  of  vowels,  and  the  gradual 
introduction  of  preceding  consonants,  special  atten- 
tion being  given  to  those  over  which  there  is  tendency 
to  stumble,  are  amongst  the  expedients  found  service- 
able, but  these  methods  are  best  applied  by  skilled 
teachers  capable  of  appreciating  the  physiological 
disabilities  of  the  pupil.  For  those  following  up  the 
subject  valuable  hints  will  be  found  in  such  treatises 
as  Dr.  Wyllie's  on  "  The  Disorders  of  Speech,"  Dr. 
W.  S.  Colman's  article  on  "  Impediments  of  Speech," 
in  Allbutt's  "  System  of  Medicine,"  vol.  viii.,  and 

*  Tuck's  Book  of  Objects  is  recommended. 


200     MENTALLY  DEFICIENT  CHILDREN 


Dr.    Leonard  Guthrie's   "  Functional  Nervous  Dis- 
orders in  Childhood/' 

There  are  two  peculiar  modes  of  speech,  occurring, 
indeed,  at  a  certain  stage  of  development  in  normal 
children,  but  apt  to  persist  in  what  Dr.  Guthrie  well 
designates  the  "  crystallised  infancy  "  of  imbeciles, 
which   call   for   special  notice   here — Eeholalia   and 
Idioglossia.    By  Eeholalia  we  mean  the  parrot-like 
imitation  of  heard  sounds  and  words  without  any 
definite  connotation  of  their  meaning  in  the  mind  of 
the  imitator.     All  children  begin  to  talk  in  this  way, 
but  the  bright  child  soon  associates  the  sound  "  Mam- 
ma "  with  his  mother,  "  Nan-na  "  with  his  nurse,  and 
so  on.     In  due  time  he  attains  a  rational  vocabulary, 
which  he  is  able  to  apply  in  naming  familiar  objects, 
and  subsequently  in  replying  to  questions.     But  with 
some  low-grade  imbeciles  this  stage  is  never  attained. 
Hearing  being,  however,  good,  and  the  commissural 
connections  between  the  auditory  centres  and  the 
organs  of  speech  being  fairly  developed,  a  kind  of 
reflex  action  is  set  up  without  the  intervention  of 
thought,  and  what  is  merely  the  echo  of  spoken  words 
is  the  result.     In  some  cases  only  the  last  words  of  a 
phrase   are   repeated,   in   others  the  whole  phrase. 
Thus  an  imbecile,  when  asked  "  What  is  your  name  ?" 
may  reply  simply,  "  Name  ";  or  another  may  vacantly 
repeat  the  whole  question  without  giving  an  answer. 
Yet  the  fond  parent  will  stoutly  maintain  his  child 
can  "  speak,"  and  will  be  much  discouraged,  if  not 
indignant,  when  told  that  such  speech  is  nothing 
worth,  and,  if  persistent  at  an  age  beyond  infancy, 
denotes  a  low  grade  of  mental  defect.     Of  course, 
with  a  quite  young  child  the  prognosis  is  more  hope- 
ful, as  there  is  a  chance,  under  persevering  training 
of  the  powers  of  observation,  of  his  attaining  the 


EDUCATIONAL  TRAINING  201 


indispensable  association  between  the  name  and  the 
thing. 

Idioglossia  (described  by  some  authors  as  a  severe 
form  of  "  lalling  "  or  lisping)  is  a  term  applied  to  a 
species  of  "  baby  language  "  persistent  beyond  the 
period  of  babyhood.  Up  to  three  or  four  years  of  age 
the  normal  child  is  apt  to  substitute  sounds  easy  of 
articulation  for  more  difficult  ones:  thus,  "  muvver  " 
is  substituted  for  "  mother  ";  "  tahee  "  for  "  father  "; 
and  so  on.  Further,  when  phrases  are  formed,  the 
pronunciation  of  the  words  may  be  grotesquely  varied, 
as  in  such  a  sentence  as  "  Ditty  is  dood  'ittle  boy  " — 
Dicky  is  good  little  boy.  Fond  and  foolish  parents 
and  nurses  sometimes  allow  themselves  to  fall  into 
similar  modes  of  language  in  conversing  with  their 
children,  and  so  correct  pronunciation  is  delayed.  A 
child,  indeed,  sometimes  builds  up  a  fancy  language 
of  his  own,  unintelligible  to  any  but  his  intimates, 
which  may,  in  fact,  seriously  handicap  him  in  the 
early  years  of  education.  In  some  of  these  cases 
there  seems  to  be  partial  auditory  or  visual  defect: 
in  others,  however,  there  may  be  some  degree  of 
mental  defect,  and  imbeciles  are  occasionally  met 
with  who  have  constructed  a  sort  of  language  of  their 
ov/n,  requiring  a  glossary  for  its  comprehension. 
Such  a  girl  of  ten,  formerly  under  Dr.  Shuttleworth's 
care,  habitually  called  him  "  Fish,"  because  her 
family  medical  attendant  had  been  a  Dr.  Fisher;  his 
wife  she  designated  "  Fish-mamma,"  and  his  daughter 
"  Fish-dolly  "J  An  old  man  glazing  the  greenhouse 
was  promptly  christened  by  her  "  Pa-putty  "!  In 
this  case  the  "  idioglossia  "  (using  this  term  in  its 
etymological  rather  than  strictly  scientific  sense) 
seems  to  have  had  a  philological  basis.  Interesting 
as  these  deviations  from  normal  speech  may  be,  they 


202      MENTALLY  DEFICIENT  CHILDREN 

are  not,  however,  to  be  encouraged;  and  in  the  case 
of  imbecile  children  especially,  every  effort  should  be 
used  to  promote  correct  pronunciation.  Training  ir 
speech  is,  indeed,  a  valuable  means  of  fixing  the 
attention  and  cultivating  muscular  co-ordination, 
and  in  these  respects,  as  well  as  for  its  specific  effect, 
may  be  regarded  as  a  valuable  adjuvant  to  other 
educational  measures. 

It  has  already  been  remarked  that,  with  the  feeble- 
minded, music  is  often  a  stepping-stone  to  speech. 
Such  children  will  frequently  hum  tunes  that  take 
their  fancy  before  they  are  able  to  articulate  words; 
but  if  attractive  tunes  set  to  words  containing  repeti- 
tions of  simple  sounds  (such  as  the  "  Ba-ba,  black 
sheep  "  of  our  old  Nursery  Rhymes*)  are  constantly 
repeated  to  them,  the  probability  is  that,  after  a  time, 
first  one  word  and  then  another  will  be  taken 
by  the  pupil,  till  the  rhyme  as  well  as  the  tune  is 
known. 

We  pass  from  the  cultivation  of  speech,  whicl 
occupies  an  intermediate  place  between  sensorial 
training  and  the  co-ordination  of  muscular  move- 
ment, to  a  consideration  of  the  exercises  more  especi- 
ally addressed  to  the  latter,  which  we  include  under 
the  comprehensive  designation  of  drill.  With  chil- 
dren of  deficient  bodily  as  well  as  mental  develop- 
ment, physical  training  is  serviceable  not  only  for 
muscular  growth  and  co-ordination,  but,  inasmuch  as 
it  demands  prompt  obedience,  for  strengthening  the 
faculty  of  attention.  The  movements  must  be  gentle 
and  adapted  to  individual  capacities,  and  even  in- 
capacities ;  mere  "  tours  de  force  "  are  inadmissible. 
Musical  drill  is  to  be  preferred — at  any  rate,  in  the 

*  Elliott's  National  Nursery  Rhymes  is  recommended  for 
this  purpose. 


EDUCATIONAL  TRAINING  203 

first  instance — whenever  practicable,  and  there  are 
now  many  excellent  manuals  on  this  subject,  such  as 
GnTs  "  Physical  Exercises,"  Alexander's  "  Musical 
Drill  for  Infants,"  etc. ,  *  which  may  be  advantageously 
used  for  exceptional  as  well  as  ordinary  children. 
Light  wooden  dumb-bells,  wands  and  rings,  are  the 
simple  apparatus  required.  The  Syllabus  of  Physical 
Exercises  issued  by  the  Inter-Departmental  Com- 
mittee for  use  in  Public  Elementary  Schools  contains 
many  that  are  also  appropriate  for  special  schools, 
including  some  for  deep  breathing.  "  Swedish  "  drill 
under  a  judicious  instructor  is  of  much  value.  For 
special  infirmities,  however,  such  as  we  frequently 
meet  with  in  the  mentally  feeble,  special  exercises 
have  to  be  devised  for  particular  cases ;  and  the  want 
of  balancing  power  many  show  is  overcome  by  "  toe- 
ing the  line,"  by  walking  the  plank,  by  stepping 
first  between  the  broad  bars  of  a  ladder  laid  hori- 
zontally on  the  ground,  and  then  from  bar  to  bar. 
Deficient  grasping  power  is  strengthened  first  by 
the  bean-bag  exercises  previously  referred  to,  then 
by  bar-bells,  and  finally  by  supporting  the  weight 
of  the  body  on  parallel  bars  or  from  the  bridge- 
ladder.  Seguin  speaks  highly  of  the  beneficial  effect 
of  a  swing  worked  by  the  child's  feet  from  a  spring- 
board in  developing  the  lower  limbs  and  strengthening 
weak  knees. 

Though  scarcely  gymnastic,  dressing  lessons  may 
be  given  with  advantage  as  class  exercises  to  children 
inexpert  in  putting  on  their  clothes.  Buttoning, 
lacing,  and  tying  bows  and  knots  bring  into  play  fine 
adjustments  of  the  fingers  frequently  deficient  in  the 
mentally  feeble.  For  practice  in  this  frames  for 

*  See  also  Physical  Education,  by  Lennox  and  Sturrock 
(Blackwood). 


204     MENTALLY  DEFICIENT 


buttoning,  lacing,  and  bow-tying,  etc.,  have  been 
patented  as  part  of  the  Montessori  method,  though 
similar  arrangements  (e.g.,  the  fastening  of  clothes 
on  a  mannikin)  have  been  in  use  in  training  institu- 
tions for  defectives  from  time  immemorial. 

With  regard  to  the  more  ordinary  school  exercises, 
we  can  only  indicate  a  few  points  on  which  special 
stress  should  be  laid  in  the  case  of  mentally  feeble 
children.  "  Facia  non  verba  "  should  be  the  guiding 
principle;  things  done  will  make  much  more  impres- 
sion than  things  merely  said;  and  whenever  prac- 
ticable, lessons  should  be  illustrated  by  objects,  for, 
as  was  remarked  by  Horace : 

"  Segnius  irritant  animos  demissa  per  aurem 
Quam  quae  sunt  oculis  subjecta  fidelibus." 

Mere  parrot-like  repetitions  of  matters  committed  to 
memory  should  be  discouraged;  nothing  should  be 
learned  by  rote  which  is  not  understood,  otherwise 
much  labour  may  be  lost,  and  at  length  we  may  find 
(with  Longfellow)  that 

"  In  an  idiot's  brain  remembered  words 
Hang  empty  mid  the  cobwebs  of  his  dreams." 

In  this  connection  we  may  lay  stress  on  the  im- 
portance of  simple  conversational  examination,  in 
which  the  pupil  is  encouraged  to  take  a  full  part, 
the  teacher  thus  ascertaining  how  much  the  child  has 
understood  of  a  lesson,  and  encouraging  the  latter  to 
add  to  his  vocabulary  and  powers  of  language. 

Object-lessons  must  start  from  the  simplest  facts 
within  the  child's  observation.  The  names  and  uses 
of  the  sense-organs,  of  the  limbs,  of  articles  of  clothing, 
of  the  furniture  of  the  room,  are  some  of  the  subjects 
upon  which  the  child's  intelligence  should  be  exer- 
cised. 

Nature-study  is  attractive   to  many,  and  is  most 


EDUCATIONAL  TRAINING  205 

useful  in  educing  and  cultivating  powers  of  observa- 
tion. 

Drawing  and  writing  are  best  taught  in  the  ele- 
mentary stage  by  free-arm  and  large  scale  exercises 
on  the  blackboard  chequer.    Drawing  lines  vertically, 
horizontally,  and  obliquely,  between  points  marked 
by  the  teacher,  and  afterwards  delineating  common 
objects  under  which  the  names  may,  with  help,  be 
printed  and  written,*  pleasantly  lead  the  children  on 
both  to  writing  and  reading,  and  with  regard  to  the 
latter  it  may  be  remarked  that  the  "  look  and  say  "  or 
"  word  "  method  is  to  be  preferred  to  the  old-fashioned 
plan  of  beginning  with  the  drudgery  of  the  alphabet,  f 
Of  course,  the  sounds  and  names  of  letters  are  learned 
at  a  later  stage,  words  being  dissected  for  this  pur- 
pose with  the  aid  of  the  letter-box.     Madame  Mon- 
tessori  has  an  ingenious  system  of  cards  upon  which 
script  letters  of  the  alphabet  cut  in  sandpaper  are 
mounted,  and  over  those  forms  the  index-finger  is 
passed  in  the  direction  in  which  the  letter  is  formed 
in  writing,  as  a  preliminary  exercise  of  the  muscular, 
tactile,  and  visual  sensations.     These  sensations  are 
associated  with  the  letter-sound,  and  writing,  and 
subsequently  reading,  both   of    script    and   printed 
letters  and  words,  are  by  this  means  acquired  with 
more  facility  than  by  the  ordinary  method.  % 

Calculation  is  the  crux  in  educating  the  mentally 
deficient.  §  Counting  (so-called)  may  be  glibly  done 

*  See  Reading  Made  Easy,  Anna  Snell.  Philip  and  Son, 
London. 

f  Gill's  "  Regina  Reading  Sheets  "  are  useful. 

J  Montessori  Method,  pp.  275,  303. 

§  It  is  remarkable  that  in  the  case  of  candidates  for  admis- 
sion to  the  London  Special  Classes  there  is  often  a  certain 
ability  to  make  small  calculations  as  to  pennyworths,  such  as 
they  have  been  accustomed  to  in  errands  for  their  parents. 
With  them  reading  seems  to  be  the  crux. 


206      MENTALLY  DEFICIENT  CHILDREN 


without  any  apprehension  of  the  meaning  of  figures; 
consequently  the  concrete  must  always  elucidate  the 
abstract.  Many  excellent  aids  are  published  for  this 
purpose,  pictorial  and  otherwise;  but  the  ingenious 
teacher  will  not  be  dependent  on  these,  as  the  child's 
own  fingers,  the  pupils  in  class,  etc.,  are  always  avail- 
able for  demonstration.  Shells,  beads,  and  the 
abacus  are  also  convenient  objects  for  counting.  To 
elucidate  the  value  of  weights,  money,  and  to  teach 
simple  calculation,  there  is  nothing  better  than  the 
"  shop  lesson/'  an  elaboration  of  the  nursery  game  of 
shop,  in  which  common  groceries  are  weighed  out  and 
paid  for  by  the  pupils,  problems  in  change  being 
tackled  practically. 

Industrial  training  is  intimately  interwoven  with 
educational  processes,  but  will  be  specially  treated  in 
the  next  chapter. 


CHAPTER  X 

INDUSTRIAL  TRAINING  AND  RECREATION 

To  complete  the  educational  fabric  appropriate  to 
mentally  deficient  children,  the  woof  of  industrial 
training  must  be  closely  interwoven  with  the  warp 
of  scholastic  exercises,  and  a  wholesome  moral  influ- 
ence must  be  the  pattern  pervading  the  whole.  In 
the  present  chapter  we  offer  some  hints  as  to  special 
modes  of  industrial  training  found  useful. 

The  "  occupations  "  of  the  Kindergarten,  selected 
so  as  to  avoid  too  minute  work,  form  attractive  and 
serviceable  preliminaries  to  handicraft.  "  Paper- 
weaving,"  for  instance,  is  an  excellent  preparation  for 
the  more  prosaic  industry  of  stocking-darning,  and 
the  "  pricker  "  used  for  perforated  pictures  will  serve 
as  an  introduction  to  the  cobbler's  awl.  Useful  as 
are  Kindergarten  occupations  for  training  the  fingers, 
and,  through  them,  the  intelligence,  the  actual  pro- 
ducts of  child-labour  in  the  way  of  bead  necklaces, 
variegated  paper  mats,  clay  and  cardboard  models, 
etc.,  have  a  distinct  value  in  developing  continuity 
of  attention  and  stimulating  further  effort,  as  the 
principle  of  achieving  a  tangible  result  is  specially 
satisfactory  to  the  mentally  feeble  child.  In  this 
respect,  industrial  training  has  an  advantage  over 
mere  book-learning,  and  it  has  been  well  remarked 
that  feeble-minded  children  learn  more  with  their 
hands  than  with  their  head.  A  judicious  industrial 

207 


208      MENTALLY  DEFICIENT  CHILDREN 

trainer,  in  fact,  develops  the  child's  intelligence  par 
passu  with  the  use  of  his  fingers. 

The  kind  of  employment  most  suitable  differs  wit 
the  particular  characteristics  of  each  case.     With  the 
majority,  outdoor  work  is  the  best  whenever  pra 
ticable,  and  we  have  repeatedly  seen  both  physica 
and  mental  development  set  going  by  such  healthy 
occupation,  when  indoor  teaching  and  employmen 
had   proved   unavailing.     Wherever    and   wheneve 
practicable,  the  regime  of  an  open-air  school  is  tt 
ideal  to  be  aimed  at  in  the  instruction  of  defective 
nervous,    and    backward    children.     Careful    suj 
vision  is,  of  course,  needed;  otherwise,  if  put  to  wee 
a  garden  the  child  may  ruthlessly  root  up  plants 
well.     The   love    of   seeing   things   grow,    howeve 
should  be  fostered,  and  the  child  will  soon  watch  wit 
interest   how   the   seedling   gradually   becomes   tl 
plant.     To  every  special  school  a  children's  garden 
should,    if  practicable,    be   attached.     The   care 
plants  in  pots,  the  growing  of  bulbs  and  germination 
of  acorns  and  chestnuts  in  glasses,  and  even  grov 
mustard  and  cress  on  moistened  flannel,  are  simpl< 
forms  of   Nature-study  which  delight  the  pupils 
the   London   sp2cial  classes.     Kindness  to   anima 
should  be  inculcated;  and,  when  this  exists,  occupa 
tion  at  a  farm  is  often  beneficial,  much  interest  bein 
taken  in  the  stock. 

For   town-bred   children,    unfortunately,    outdo 
occupations  are  not,  as  a  rule,  available.     There  ar 
however,   many   varieties   of  manual  training  nov 
commonly  practised  in  connection  with  our  publi 
elementary  schools  and  in  technical  classes  in  whic 
the  mentally  feeble  may  participate.     The  ma 
of  woollen  and  cocoanut  fibre  mats,  cloth  and  ca 
weaving,   simple  brush  and  basket  making,   strav 
plaiting,  sashline-making,  are  some  of  the  arts  easil 


INDUSTRIAL  TRAINING  AND  RECREATION  209 

acquired  which  furnish  a  very  pleasing  result;  and 
the  same  may  be  said  of  macrame  work,  which  in  our 
experience  is  an  excellent  exercise  for  those  subject 
to  finger  twitches.  We  have  elsewhere  remarked 
that  these  athetotic  patients  frequently  possess 
graphic  and  artistic  ability;  and  for  such,  wood- work 
and  even  wood-carving  form  congenial  employments. 
It  is  marvellous  how,  by  persevering  exercise  of  will- 
power, such  pupils  gradually  overcome  their  spas- 
modic movements,  and  are  at  length  able  to  execute 
quite  fine  work  with  the  chisel  and  graving  tool. 
Girls  with  athetoid  affections  often  become,  under 
training,  good  needlewomen,  putting  in  their  stitches 
with  great  regularity.  The  mysteries  of  knitting, 
crochet,  and  other  fancy  work,  are  also  mastered  by 
them;  and  we  have  seen  a  mentally  feeble  girl, 
crippled  as  to  her  right  hand  by  spastic  contractures, 
do  fine-art  needlework  with  her  left.  At  some  of 
the  institutions  lace-making  is  carried  on  with  con- 
siderable success.  An  excellent  handbook  for 
trainers,*  entitled  "  Industries  for  the  Feeble-minded 
and  Imbecile/'  has  been  published  by  Mr.  A.  Bick- 
more,  the  able  Craftsmaster  of  the  Darenth  Industrial 
Colony.  Practical  advice  is  therein  given  as  to  the 
various  industries  found  serviceable  in  a  Poor  Law 
institution,  amongst  which  he  mentions,  in  addition  to 
wood- work  and  building  handicrafts,  such  occupa- 
tions as  printing,  book-binding,  envelope  and  paper- 
bag  making,  cardboard-box  making,  tin-ware  and 
metal- plate  work,  as  well  as  the  more  ordinary  trades 
of  shoemaking,  tailoring,  and  brash  and  basket 
making. 

The  practical  needs  of  after-life  must,  of  course,  be 
borne  in  mind  in  selecting  a  particular  employment. 

*  "  Industries  for  the  Feeble-minded  and  Imbecile,"  by 
A.  Bickmore.     London:   Adlard  and  Son,  1913. 

14 


210      MENTALLY  DEFICIENT  CHILDREN 


The  gentleman's  son,  though  comfortably  provided 
for,  will  be  all  the  happier  for  having  an  occupation 
to  turn  to;  and  for  such,  carpentry,  wood-carving, 
and  even  turning,  are  good  indoor  pursuits,  whilst 
gardening  and  farming  are  specially  appropriate. 
Young  ladies  who  by  leason  of  their  feeble-minded- 
ness  will  be  to  some  extent  debarred  from  the  ordinary 
pursuits  of  society  should  be  encouraged  to  take  an 
interest  in  domestic  matters,  and  to  assist  in  arranging 
floral  decorations.  They  may  also  employ  them- 
selves in  a  variety  of  fancy  work ;  and  if  they  possess 
any  artistic  or  musical  tastes  these  should  be  culti- 
vated. 

For  children  of  the  working  class  some  occupation 
which  they  can  carry  on  under  the  eye  of  their  parents 
is  desirable.  If  they  live  in  the  country,  they  should 
be  trained  for  agricultural  labour,  or  to  assist  in 
garden  work.  If  in  town,  some  work  which  they  can 
practise  at  home,  or  in  small  establishments,  such  as 
cobblering  or  tailoring,  basket  or  doormat  making, 
should  be  taught  them;  for  obvious  reasons  they  are 
unfit  for  factory  work.  It  may  be  interesting  to  add 
that  recent  after-care  statistics  show  a  considerable 
number  of  ex-pupils  of  special  schools  serving  with 
the  colours  (sixty  so  reported  from  Birmingham*  and 
seventy-seven  from  London)  ;|  and  in  the  Boer  War 
an  ex-patient  of  the  Royal  Albert  Institution  ren- 
dered creditable  service  in  the  I3th  Hussars,  assisting 
at  the  relief  of  Ladysmith,  but  ultimately  succumb- 
ing to  an  illness  contracted  in  his  duties.  The  dis- 
cipline and  outdoor  life  of  the  army  seem,  indeed, 
beneficially  suitable  for  the  more  intelligent  cases  of 

*  .Report  of  Birmingham  Special  Schools  After-care  Sub- 
committee, June,  1915. 

f  After-care  Association  for  Elder  Mentally  Defective 
Children  of  London,  1914. 


INDUSTRIAL  TRAINING  AND  RECREATION  21  f 


good  physique.  Girls  should  be  trained  to  work  in 
the  house  and  the  laundry,  to  cook,  and  to  make 
garments.  Many  imbeciles  who  have  been  brought 
up  in  institutions  are  quite  capable  of  earning  their 
living  under  favourable  circumstances,  but  the  "  res 
angusta  domi,"  and  (too  frequently  also)  parental 
incapacity,  are  not  favourable  circumstances,  and 
consequently,  if  discharged  to  their  own  homes,  there 
is  much  risk  of  training  being  thrown  away.  This 
is  one  of  the  arguments  in  favour  of  permanent 
custodial  working-homes  and  colonies  being  instituted 
by  private  benevolence  and  public  authorities  for 
mentally  deficient  children  capable  of  useful  industry. 
Recreation. — For  mentally  feeble,  as  well  as  other 
children,  the  maxim  "  ne  quid  nimis  "  is  especially 
appropriate.  Study  and  occupation  must  be  varied; 
signs  of  fatigue  watched  for  and  guarded  against ;  and 
relaxation  is  essential.  But  care  must  be  taken  that 
relaxation  does  not  degenerate  into  loafing;  suitable 
active  recreation  must  be  supplied.  Mentally  deficient 
children,  particularly  those  of  low  grade,  are  apt  to  be 
of  solitary  habit;  they  have  no  idea  of  combination, 
even  for  games.  Games  of  ball  may,  indeed,  be  prac- 
tised alone,  but  they  are  much  more  useful  when 
played  with  others  in  the  form  of  rounders,  cricket, 
hockey,  or  tennis.  Football  can  only  be  played 
under  special  conditions — neither  Rugby  nor  Asso- 
ciation Rules;  it  forms  a  valuable  exercise  not 
only  for  the  limbs  but  for  the  wits.  Even  golf 
may  be  played  by  feeble-minded  people.  Games  at 
marbles  are  good  for  finger  training.  Trundling 
hoops,  playing  horses,  etc.,  should  also  be  encouraged. 
Skipping  is  an  excellent  exercise,  for  boys  as  well  as 
girls,  so  long  as  the  heart  is  all  right.  The  game  of 
battledore  and  shuttlecock  is  good  training  both  for 
hand  and  eye.  Of  indoor  recreations,  dancing  is  to 


'212      MENTALLY  DEFICIENT  CHILDREN 


be  specially  commended  as  tending  to  improve 
carriage  and  diminish  the  tricks  of  gait  which  often 
mark  the  mentally  deficient.  "  Musical  Chairs/' 
"  Post,"  and  similar  games,  promote  both  activity 
and  intelligence.  Bagatelle  is  a  good  indoor  diver- 
sion, the  scoring  being  of  educational  value  ;  and 
the  game  of  dominoes  helps  in  ideas  of  number. 
Even  card  games  may  be  played  by  the  more  intelli- 
gent, and  whist  is  an  excellent  exercise  of  memory. 
The  "  children's  hour,"  so  valuable  an  institution  in 
normal  nurseries,  is  specially  useful  with  the  mentally 
feeble,  who  often  require  to  be  taught  to  play,  and 
sleep  better  for  the  romp  before  retiring. 

The  love  for  music  which  is  common  with  the 
mentally  feeble  suggests  attendance  at  concerts  and 
at  musical  services  as  appropriate  modes  of  enjoy- 
ment. With  some  a  considerable  sense  of  humour 
exists,  and  theatrical  performances,  especially  when 
abounding  in  comic  situations,  are  much  appreciated. 
It  is  of  importance  that  entertainments  at  which 
mentally  deficient  children  are  present  should  be  of  a 
refined  character.  Coarse  buffoonery  and  scenes  of 
violence — provocative  to  some  weak  minds  of  imita- 
tion— should  be  carefully  avoided.  In  these  days 
the  cinema  show  can  hardly  be  tabooed,  but  care 
is  necessary  as  to  the  character  of  the  pictures. 

In  concluding  this  chapter  we  may  note  with  satis- 
faction the  increasing  importance  which,  as  the  result 
of  experience,  has  of  late  years  been  attached  to  the 
place  of  manual  work  in  the  educational  curriculum 
of  the  mentally  deficient  child.  In  his  Annual 
Report  for  1909  the  Chief  Medical  Officer  of  the 
Board  of  Education  writes  as  follows:  "The  intro- 
duction of  manual  instruction  into  the  curriculum 
receives  its  practical  sanction  from  the  certainty 
that  any  attempt  to  train  the  feeble-minded  child 


INDUSTRIAL  TRAINING  AND  RECREATION  213 


through  the  abstract  literary  methods  of  the  elemen- 
tary school  must  be  doomed  to  failure,  and  the 
mentally  defective  children  will  never  be  able  to 
earn  their  living,  entirely  or  partially,  by  any  other 
than  manual  means/'  He  proceeds  to  chronicle  the 
developments  in  industrial  instruction  that  had 
taken  place  in  the  Special  Schools  of  the  London, 
Birmingham,  and  Liverpool  Education  authorities, 
and  in  an  appendix  the  subjoined  "  Specimen  Cur- 
ricula for  Schools  for  the  Mentally  Defective/1  which 
it  will  be  noticed  contain  a  gradually  increasing 
proportion  of  manual  training  with  advancing  age, 
are  set  forth. 

I. — A  Specimen  Curriculum  for  Junior  Schools. 

LONDON  COUNTY  COUNCIL — KENNINGTON  ROAD  JUNIOR 
SCHOOL. 

Approximate  Analysis  of  Time-Table  for  One  Week. 

Hrs.  Mins. 

Manual  and  Sense  Training       -         -         -       8     30 
Elementary   Subjects   (including   Scripture 

and  Registration)  7     55 

Physical    Education 120 

Voice- training,  Singing,  and  Recitation        -       2     15 
Recreation          -         -         -         -         -         -230 


Total      -         -         -         -     22     30 

Subjects  of  Manual  Instruction  (Three  Stages). 

First  Stage. — Drawing  and  Crayon  Work,  Canvas  and 
Kindergarten,  Sewing,  easy  Cane  Weaving,  easy  Knotting, 
easy  Loom  Weaving,  Modelling  in  Plasticine. 

Second  Stage. — Scale  and  Free  Drawing,  Paper-cutting, 
Loom  Weaving,  Straw  Weaving,  Cane  Weaving,  easy  Rug- 
making,  Canvas  Work. 

Third  Stage. — Painting,  Strip  Work,  Chair-caning,  Basket 
Work,  Rug-making,  Knitting,  Needlework,  Cookery,  Laundry. 


2i4       MENTALLY  DEFICIENT  CHILDREN 


II.  —  A  Specimen  Curriculum  for  Elder  Boys. 

LONDON  COUNTY  COUNCIL  —  BROOK  GREEN  SENIOR  SCHOOL 

(ELDER  BOYS). 

Approximate  Analysis  of  Time-Table  for  One 

Week. 

Classes  1,2,        Classes  2,  4, 

and  3. 

and  6. 

Hrs.  Mins. 

Hrs.   Mins. 

Manual  Work    -         -         -     n     20 

12          0 

Elementary    Subjects    (in- 

cluding  Scripture  and 

Registration)           -         -       6     10 

5     30 

Physical  Education   -         -30 

3       ° 

Singing  and  Recitation       -       i     10 

I        10 

Recreation                   -         -       2     30 

2       30 

Total 


24     10 


24     10 


Subjects  of  Manual  Instruction. 

Drawing,  Clay  Modelling,  Gardening,  Carpentry,  Joinery, 
Wood  Carving,  Metalwork,  Tailoring,  Boot  Making  and 
Mending. 

III. — A  Specimen  Curriculum  for  Elder  Girls. 

LONDON    COUNTY   COUNCIL — PRIORY  ROAD  SENIOR  SCHOOL 
(ELDER  GIRLS). 

Approximate  Analysis  of  Time-Table  for  One  Week. 


Classes 

A  andB. 

Hrs. 

Mins. 

Manual  Work    - 

10 

50 

Elementary    Subjects    (in- 

cluding    Scripture     and 

Registration) 

6 

20 

Physical  Education   - 

i 

15 

Singing  and  Recitation 

I 

35 

Recreation 

2 

30 

Total       -         -         -     22     30  22     30 

Subjects  of  Manual  Instruction. 

1.  Drawing  to  Scale,  Colour  Drawing,  Clay  Modelling. 

2.  Needlework,   Fancy    Sewing,    Mending     of     Garments, 
Catting-out  (paper)  Patterns,  Use  of  Sewing  Machine. 

3.  Cookery,  Laundry,  Housewifery. 


INDUSTRIAL  TRAINING  AND  RECREATION    215 


From  returns  kindly  furnished  by  Mrs.  Burgwin, 
we  learn  that  in  the  London  County  Council  Special 
Schools  for  Elder  Boys  the  proportion  of  time  now 
devoted  to  handicrafts  is  even  greater  than  that  speci- 
fied above,  varying  from  fifteen  hours  a  week  for  the 
more  advanced  boys  to  ten  for  beginners.  The 
balance  of  the  twenty-five  hours  now  forming  the 
school  week  in  Elder  Boys'  Departments  is  devoted 
to  ordinary  classwork.  A  typical  Time- Table  is 
printed  in  Appendix  D,  pp.  262-263. 


CHAPTER  XI 
MORAL  TRAINING 

IF  good  moral  training  be  a  prime  essential  in  every 
system  of  education,  it  is  specially  so  in  the  case  of 
mentally  deficient  children.  Not  that  the  mentally 
feeble  child  is  by  nature  morally  worse  than  the 
ordinary  child,  but  his  weakness  makes  him  more 
open  to  suggestion,  so  that  an  evil  example — not  to 
say  precept — may  in  his  case  be  specially  injurious. 
It  is  a  curious  and  lamentable  fact  that  when  the 
inhibitive  nerve  power  is  weakened,  either  from 
disease  or  from  original  defect,  the  lower  nature  is 
apt  to  assert  itself,  both  in  deed  and  word;  and  it  is 
sometimes  a  matter  of  surprise  how  mentally  feeble 
persons,  notwithstanding  good  surroundings,  give 
vent  to  the  most  evil  language,  profane  or  obscene. 
Even  the  hasty  word,  carelessly  uttered,  may  be  taken 
up  by  the  weak-minded  child,  and  reproduced  on 
some  inconvenient  occasion.  Great  care,  therefore, 
should  be  taken  by  all  in  charge  of  such  cases  to  be 
choice  in  their  language,  as  well  as  correct  in  their 
conduct;  for  imitation  is  characteristic  of  the  class. 
On  the  other  hand,  a  good  moral  influence  is  insensibly 
exercised  by  those  who  are  judicious,  and  the  choice 
of  a  teacher  or  attendant  is  a  matter  of  supreme  im- 
portance, moral  as  well  as  mental  qualifications 
calling  for  consideration. 

As  regards  moral  discipline,  coaxing,  not  coercion; 
216 


MORAL  TRAINING  217 


must  be  the  guiding  principle.  With  the  mentally 
deficient  especially,  "force  is  no  remedy";  the 
"  cowed  "  child  will  be  a  cowardly  child,  with  no 
pluck  or  spirit  to  advance  itself.  As  Roger  Ascham 
remarks  with  regard  to  the  ordinary  pupil,  he  must 
in  no  wise  be  "  beaten  into  the  hatred  of  learning  "; 
and  not  only  in  the  scholastic,  but  in  the  general 
management  of  the  mentally  deficient  child,  love 
must  be  the  all-pervading  principle.  At  the  same 
time  judicious  firmness  must  be  exercised;  and  con- 
sistency in  word  and  deed,  combined  with  tact,  are 
essential  to  moral  influence.  The  mentally  feeble, 
like  the  ordinary  child,  soon  finds  out  to  whom  he 
must  render  prompt  obedience.  It  is  specially  true 
of  him  that  he  cannot  "  serve  two  masters/'  and 
attempts  at  dual  control  are  apt  to  result  in  failure. 
This  should  be  borne  in  mind  in  making  arrangements 
with  a  governess,  whose  influence  should  not  be  im- 
paired by  unnecessary  parental  interference. 

A  system  of  rewards  and  punishments,  modified, 
of  course,  to  meet  individual  peculiarities,  is  effica- 
cious with  this  class  as  with  others.  Mentally 
deficient  children  are  frequently  eager  to  obtain  the 
commendation  of  their  superiors,  and  sometimes 
withholding  commendation  will  make  sufficient  im- 
pression ;  at  other  times  words  of  reproof  are  necessary. 
The  Regulations  of  the  Board  of  Control  prohibit  the 
administration  of  corporal  punishment  to  any  patient 
in  institutions  for  mental  defectives.  It  is  true  that 
corporal  punishment  is  rarely  beneficial;  yet  there 
are  cases  where  pain  wantonly  inflicted  on  others  is 
appropriately  visited  by  pain  inflicted  on  the  offender. 
Sometimes  an  appeal  to  the  mind  is  best  made  through 
the  stomach:  in  many  instances  the  cutting  off  of 
some  favourite  article  of  food  (e.g.,  pudding  or  sugar) 
from  the  day's  dietary  will  mark  disapproval  better 


218      MENTALLY  DEFICIENT  CHILDREN 

than  any  other  procedure.  The  deprivation  of  some 
looked-for  pleasure,  such  as  attending  an  entertain- 
ment or  going  to  church,  will  be  efficacious  in  many 
cases;  with  younger  children  the  temporary  for- 
feiture of  a  favourite  toy  is  all  that  is  necessary. 
Older  cases  occasionally  (perhaps  exceptionally) 
develop  a  keen  interest  in  the  value  of  money,  and 
such  are  best  touched  by  an  abatement  of  their  allow- 
ance, or  the  enforcement  of  a  fine. 

With  the  growth  of  intelligence  it  must  be  point 
out  that  harm,  followed  by  punishment,  inevitably 
results  from  evil  doing,  and  that 

"  Though  the  mills  of  God  grind  slowly,   yet  they  grind 

exceeding  small; 

Though  with  patience  He  stands  waiting,  with  exactness 
grinds  He  all." 

The  weak-minded  person  is  not  to  be  encouraged  in 
the  notion— but  too  easily  taken  up  with  dangerous 
consequences — that,  because  he  is  not  quite  like  other 
men,  he  is  less  responsible  for  his  actions.  From 
foibles  he  should,  of  course,  be  guarded;  and  he  should 
learn  to  respect  his  neighbour,  and  act  on  the  legal 
maxim,  "  Sic  utere  tuo,  ut  alienum  non  Isedas."1* 

Perhaps  the  most  trying  case  we  are  called  on  to 
deal  with  amongst  children  mentally  abnormal— 
though,  indeed,  there  may  be  but  little  evidence  of 
intellectual  deficiency — is  that  of  the  moral  imbecile. 
The  despair  of  his  parents,  the  bete  noir  of  the  institu- 
tion, the  perplexing  puzzle  of  the  jurist — he  seems 
to  be  the  ill-fated  product  of  inherited  nervous 
instability  and  ancestral  criminal  instincts.  In  the 
Mental  Deficiency  Act,  1913,  moral  imbeciles  are 
defined  as  "  persons  who  from  an  early  age  display 
some  permanent  mental  defect,  coupled  with  strong 
vicious  pr  criminal  propensities,  on  which 


MORAL  TRAINING  219 

ment  has  had  little  or  no  deterrent  effect/'  It  must 
be  noted  that  three  conditions  qualify  this  definition : 
(a)  mental  defect  coupled  with  the  moral  infirmity 
shown,  (b)  displayed  from  an  early  age,  and  (c)  of  a 
permanent  character.  In  practice  it  will  be  found 
that  these  qualifications  materially  narrow  the  appli- 
cation of  the  term  "  moral  imbecile  "  for  legal  pur- 
poses. If,  however,  we  may  judge  from  a  legal 
decision  given  (in  1914)  in  the  case  of  a  highly  edu- 
cated B.Sc.  London  and  Whit  worth  scholar  convicted 
at  the  Old  Bailey  of  fraudulent  conduct,  but  subse- 
quently dealt  with  by  the  Judge  as  a  moral  imbecile 
under  the  Mental  Deficiency  Act,  it  would  appear 
that  but  slight  evidence  of  mental  defect  may  be  held 
sufficient. 

With  regard  to  the  class  of  moral  defectives  as 
found  in  the  London  schools,  we  venture  to  extract 
from  Dr.  Kerr's  Report,  presented  to  the  London 
County  Council  Education  Committee  in  May,  1909, 
the  following  apposite  paragraphs : 

"  Moral  Defectives  and  Permanent  Custodial  Treatment. 
—The  necessity  for  compulsory  powers  of  detention  in 
custodial  schools  till  sixteen,  and  later  for  the  rest  of 
life,  of  certain  moral  defectives  is  a  most  pressing  matter. 
For  instance,  just  as  we  find  in  cases  of  pure  word-blind- 
ness a  defect  of  a  particular  region  of  the  brain,  some- 
times as  an  hereditary  failing  which  may  occur  in  children 
normal  in  other  respects,  or  combined  with  any  amount 
of  other  defect,  from  mere  dulness  to  low-grade  mental 
defect,  imbecility,  or  idiocy,  so  cases  are  found  of  morally 
defective  children  who  vary  in  mental  capacity  from 
some  cases  which  are  exceedingly  clever  in  other  respects 
to  children  who  are  so  bad  as  to  be  classed  as  imbecile. 
Very  commonly,  through  such  individuals  being  on  what 
might  be  considered  as  a  lower  scale  of  mental  develop- 
ment than  normal,  the  emotions  are  much  more  developed 
relatively  than  the  intellectual  qualities  which  give  re- 


220      MENTALLY  DEFICIENT  CHILDREN 

straint,  so  that  they  are  exceedingly  plausible  in  spee< 
and  have  a  peculiarly  attractive  gift  of  adapting  the: 
selves,  smiles  or  tears  being  available  with  equal  ea 
according  to  their  environment.  There  are  great  difl< 
ences  in  the  way  the  defect  is  manifested.  It  is  aim 
impossible  yet  to  classify  them,  but  a  provisional  arrang 
ment  might  be  made  into — (i)  Passive;  (2)  Active. 

"  i.  PASSIVE  CASES  (ONLY  PASSIVE  TROUBLE  i 
SCHOOL  CONDUCT). — (a)  Children  who  have  irregula: 
but  recurrent  outbursts,  showing  moral  defect  in  slight 
degrees  amounting  to  uncontrollable  bad  temper,  often 
with  a  complete  heedlessness  of  all  correction  or  advice, 
and  very  often  a  tendency  to  roam  or  wander  away. 
These  cases  are  probably  of  an  epileptic  nature,  and 
require  detention,  and  are  to  be  regarded  as  cases  of 
disease. 

"  (b)  Children  who  seem  merely  not  to  be  amenable 
to  discipline.     This  is  a  large  class,  and  I  think  a  very 
large  proportion  would  be  taught  habits  of  obedience  b; 
regular  and  inflexible  corporal  punishment.     Most 
them  are  subjects  for  industrial  training  later  on,  bu 
they  often  present  other  defects — e.g.,  word-blindness. 

"2.    ACTIVE    CASES     (ACTIVE    TROUBLES    TO    TH 
TEACHERS). — (a)   Children  who  are  only  differentiat 
from  the  first  of  the  class  above  by  their  violence  am 
destructiveness  in  their  outbursts  of  rage,  almost  unpro 
voked  at  times,  and  quite  irregular.     For  the  greate: 
part  of  their  time  such  children  are  inoffensive,  some- 
times clever,  often  dull,  stupid,  or  even  sullen,  but  in  a 
rage  behave  as  uncontrollable  lunatics.     They  are,  how- 
ever, comparatively  rare. 

"  (b)  Murderous  tendencies  from  pure  cruelty  (quarrel- 
ling, pinching,  biting  others,  infliction  of  cruelty  on 
young  children,  or  killing  of  animals).  In  particular 
cases  these  children  are  very  objectionable  in  school. 
Manslaughter  has  been  committed  by  children  of  inno- 
cent, pleasant,  and  in  one  case  almost  angelic  appear- 
ance. There  is  every  grade  of  mental  attainment  among 
these  children  afflicted  with  this  lust  of  cruelty. 

(c)  Interference  with  the  opposite  sex  shows  itself  in 


MORAL   TRAINING 


boys,  but  most  objectionably  in  girls.  There  is  every 
grade,  from  the  natural  attraction  of  the  sexes  to  the 
most  flagrant  and  offensive  behaviour  requiring  the 
attention  of  the  police.  Here,  again,  mental  capacity 
may  vary  from  children  who  are  quite  normal  in  school- 
work  to  those  who  are  low-grade  mental  defectives. 
This  particular  type  of  girl  is  most  difficult  to  deal  with. 
It  is  of  vital  importance  to  place  them  in  residential 
schools,  and  separate  them  from  other  children  of  the 
same  age,  because,  though  numerically  few,  they  con- 
stitute a  most  vicious  element,  a  leaven  of  evil  among 
the  girls  with  whom  they  are  compelled  to  mix.  It  is 
principally  for  the  sake  of  others  that  this  policy  is 
proposed. 

*  *  *  *  * 

"  A  much  more  humane  and  scientific  idea  than  mere 
segregation,  and  more  economical  to  the  State,  would  be 
to  deprive  such  individuals  of  the  objectionable  powers 
and  capacities,  at  the  same  time  relieving  them  of  the 
passions  and  desires  before  the  time  at  which  these 
develop/' 

The  last  paragraph  refers,  of  course,  to  methods  of 
surgical  sterilisation,  which  during  the  last  few  years 
have  been  strongly  advocated  in  some  quarters.  In 
America  eight  of  the  States  of  the  Union  have  laws 
which  authorise  or  require  such  procedure  in  certain 
classes  of  defectives  and  degenerates — viz.,  Indiana, 
Connecticut,  Washington,  California,  Iowa,  Nevada, 
New  Jersey,  and  New  York;  the  first  (in  Indiana) 
having  been  enacted  in  1907,  the  last  (in  New  York) 
in  1912.  In  all  these  enactments  the  determination 
of  the  individual  to  be  operated  on  is  entrusted  to  a 
State  Commission  or  Board,  and  vasectomy  (excision 
of  a  portion  of  the  vas  deferens)  in  the  male,  and 
salpingectomy  (excision  of  the  Fallopian  tubes)  in  the 
female,  are  the  operations  usually  resorted  to.  The 
conclusions  arrived  at  by  a  committee  of  well-known 


222     MENTALLY  DEFICIENT  CHILDREN 


experts,  who  recently  investigated  the  results  attainec 
under  this  legislation,  are  that,  while  vasectomy  is 
simple  innocuous  method  of  procuring  sterility  in  the 
male,  though  not  always  permanently,  and  not  other- 
wise interfering  with  sexual  function,  there  is 
certain  risk  to  life  in  the  case  of  females,  and  occa- 
sionally of  serious  mental  disturbance  in  both  sexes 
On  the  whole,  American  experience  does  not  afford 
enthusiastic  support  to  the  oft-vaunted  practice  of 
surgical  sterilisation,  and  it  is  stated  that,  "  except 
in  Indiana  and  in  California,  little  or  nothing  has  beer 
done  to  carry  out  the  laws  authorising  it."* 

The  police  in  many  large  centres  of  population 
know  children,  members  sometimes  of  respectable 
families,  whom  they  shrink  from  prosecuting,  but 
whom  they  cannot  otherwise  restrain  from  crime. 
Schools  of  the  highest  class  are  not  unfrequentl} 
confronted  with  the  problems  that  arise  from  the 
presence  of  an  undesirable  pupil  of  this  type.  He, 
or  she,  may  combine  the  most  innocent,  sometimes 
engaging,  external  appearance  with  an  inner  depth 
of  cunning  and  iniquity  which  requires  to  be  ex- 
perienced to  be  appreciated.  The  sudden  impulses 
to  mischief  occurring  in  these  cases  are  sometimes 
of  an  epileptoid  character,  and  paroxysms  may  in 
such  cases  be  cut  short  by  bromides.  But  as  a  rule 
moral  discipline  is  of  little  avail;  punishment  may  be 
administered,  and  professions  of  penitence  called 
forth,  only  to  be  forgotten  as  soon  as  the  mental  dis- 
turbance again  recurs.  The  original  author  has  a 
vivid  recollection  of  three  nice-looking  children,  sisters 
and  brother,  formerly  under  his  care,  who  at  times 
would  appear  models  of  propriety,  while  at  others 
they  had  all  the  characteristics  of  little  demons. 
With  innocent  expression  they  would  furtively  accom- 

*  Journal  of  Psycho-Asthenics,  June,  1914. 


MOKAL  TRAINING  223 

plish  the  most  abominable  mischief,  and,  after  meekly 
acknowledging  the  error  of  their  ways,  would  empha- 
sise their  apology  by  a  missile  flung  at  the  head  of 
the  person  who  had  attempted  to  bring  them  to  re- 
pentance !  Such  children  would  in  old  time  have 
been  called  "possessed";  now  they  are  classified 
as  cases  of  moral  imbecility  or  juvenile  insanity. 
Dr.  Samuel  J.  Fort  has  described  similar  cases  under 
the  title  of  "  Psychical  Epilepsy  "*;  and  in  his  Goul- 
stonian  Lectures  for  1902  Dr.  G.  F.  Still  points  out 
that  a  severe  bout  of  convulsions  in  infancy  is  some- 
times followed  by  arrest  of  moral  development. 
Arson  is  a  crime  that  has  a  special  fascination  for 
these  degenerates,  and  so  has  the  placing  of  obstruc- 
tions on  railways.  The  catastrophes  that  may  result 
in  consequence  furnish  a  strong  argument  for  per- 
manent detention.  It  occasionally  happens,  however, 
that  moral  aberrations  of  a  more  transient  character 
are  met  with  in  young  people  of  neurotic  heritage, 
whose  unstable  mental  equilibrium  has  been  upset  by 
the  strain  of  pubescence.  Such  are  the  cases  in  which 
a  propensity  to  petty  peculation  develops  itself  in  boys 
or  girls  who  have  previously  borne  good  characters  at 
a  high-class  school;  it  is  sometimes  accompanied  by 
other  eccentricities  of  conduct,  and  is  often  apparently 
motiveless.  Our  experience  has  been  that  on  re- 
moval to  an  appropriate  environment  many  of  these 
cases  improve  under  tactful  management,  and  when 
the  stress  of  pubescent  development  has  subsided, 
there  may  be  a  gradual  restoration  of  moral  control. 
In  other  disappointing  cases  we  find  considerable 
improvement  in  intelligence  and  manual  skill  with 
actual  deterioration  of  the  moral  sense.  Intelli- 
gence and  skill  which  have  been  acquired  are,  indeed, 

*  Proc.  Association  Amer.  Institution  for  Idiotic  and  Feeble- 
minded Persons,  1894,  p.  400. 


224      MENTALLY  DEFICIENT  CHILDREN 

used  for  evil  purposes;  and  Dr.  Kerlin,  the  former 
Superintendent  of  the  Pennsylvania  Institution,  who 
paid  much  attention  to  this  class,  came  to  the  con- 
clusion "  that  to  educate  them  often  gave  them  added 
power  for  evil,  and  that  they  should  not  be  allowed 
to  prey  upon  society/'  He  claimed  that  mora 
imbeciles  "  should  be  treated  in  a  class  apart  in 
buildings  by  themselves,  as  they  affect  the  methods 
of  living  and  training  of  the  rest/'*  Dr.  Jules  Morel 
has,  in  an  able  communication  to  the  Medico-Psycho- 
logical Association,  f  advocated  the  establishment 
of  special  institutions,  intermediate  between  re- 
formatories and  asylums,  wherein  "  such  persons 
should  be  objects  of  prophylactic  treatment  against 
crime/'  Similar  views  have  been  expressed 
Dr.  Barr,  who  succeeded  Dr.  Kerlin  in  charge  of  the 
Pennsylvania  Institution.  In  his  communication  tc 
the  section  of  the  Royal  Commission  on  the  Care  anc 
Control  of  the  Feeble-minded  which  visited  America, 
he  stated,  in  reference  to  the  patients  under  his  charge 
at  Elwyn:  "  Many  of  the  children  are  absolute  crimi- 
nals. Some  are  the  victims  of  circumstances,  but  the 
absolutely  bad  children  we  cannot  do  anything  with. 
We  have  fifty  to  seventy-five  of  them.  I  think  our 
Government  should  take  up  the  question  of  these 
children.  I  should  have  these  form  a  national  colony 
on  the  bad  lands  of  the  West,  to  be  taken  care  of  under 
military  discipline/'!  In  our  own  country  the  Board 
of  Control  are  dealing  with  the  problem  by  the  pro- 

*  Forty-First  Annual  Report,  Pennsylvania  Training  School. 
Philadelphia,  1893. 

f  Journal  of  Mental  Science,  vol.  xl.,  p.  599. 

|  Report  of  the  Members  of  the  Royal  Commission  on  the  Care 
and  Control  of  the  Feeble-minded  upon  their  Visit  to  American 
Institutions  (vol.  vii.). 


MORAL  TRAINING  225 

vision  of  a  State  Institution  for  defectives  of  marked 
dangerous  or  violent  propensities. 

There  is  need  for  caution  in  institution  arrange- 
ments for  the  mentally  feeble  class  that  egoism,  which 
often  springs  from  their  solitary  instincts,  be  not 
pandered  to,  but  rather  that  altruistic  views  should 
be  enforced.  The  golden  rule  that  even  the  feeble- 
minded should  "  do  unto  others  as  they  would  be 
done  by  "  should  be  inculcated.  Happily,  such  per- 
sons are  often  susceptible,  not  only  to  moral,  but  to 
religious  influences.  Their  very  simplicity  leads  them 
to  accept  without  hesitation  ideas  of  a  Universal 
Father,  who  is  at  the  same  time  an  all-seeing  God, 
of  a  loving  Saviour,  and  of  a  sanctifying  Spirit ;  and 
however  imperfect  may  be  their  comprehension  of 
these  mysteries,  there  is  no  doubt  that  such  notions 
tend  to  exert  a  wholesome  restraining  influence  upon 
conduct. 


CHAPTER  XII 
RESULTS  AND  CONCLUSIONS 

IN  this  closing  chapter  we  propose  to  discuss  the 
results  which  have  accrued  from  the  system  of  treat- 
ment and  training  we  have  endeavoured  to  describe, 
and  to  formulate  some  conclusions  as  to  the  value  of 
the  work. 

The  pessimism  of  the  early  part  of  the  nineteenth 
century  has  fortunately  been  put  out  of  court  by  the 
results  obtained.  Nearly  every  case  is  amenabli 
to  training,  and  capable  of  improving  to  a  certair 
extent,  with  the  result  of  rendering  existence  healthier 
and  happier,  and  less  burdensome  to  others.  A  con- 
siderable proportion  can  be  "  taught  to  conform  tc 
moral  and  social  law,  and  rendered  capable  of  order/'* 
and  many  "  become  capable  of  the  ordinary  trans 
actions  of  life  under  friendly  control,  of  understandir 
moral  and  social  abstractions  "  j ;  while,  in  the  specia 
case  of  cretins  and  other  aments  suffering  from  some 
glandular  deficiency,  almost  complete  amelioratior 
of  the  symptoms  may  be  obtained. 

The  experience  of  institutions  for  training  youthful 
defectives  both  in  this  country  and  in  America  goes 
to  confirm  the  accuracy  of  Seguin's  prognostications. 
The  statistics  of  the  Royal  Albert  Asylum,  Lancaster, 

*  E.  Seguin,  Idiocy,  c:nd  its  Treatment  by  the  Physiological 
Method,  New  York,  1866. 
t  Ibid. 

226 


RESULTS  AND  CONCLUSIONS  227 

gathered  by  Dr.  Shuttleworth  in  1890,  with  regard  to 
the  after-career  of  pupils  discharged  on  completion 
of  their  seven  years'  training,  showed  that  10  per 
cent,  were,  or  had  been,  earning  wages;  that  5  per 
cent,  were  remuneratively  employed  at  home;  and 
that  3-5  per  cent.,  in  addition,  were  capable  of  earning 
wages  if  suitable  situations  could  be  found  for  them. 
About  22  per  cent,  were  reported  to  be  more  or  less 
useful  to  their  friends  at  home,  while  another  22  per 
cent,  were  said  to  be  of  little  or  no  use;  29  per  cent, 
had  gravitated  to  workhouses  and  lunatic  asylums; 
the  remainder  (8*5  per  cent.)  had  died.  In  the  Jubilee 
Report  of  the  Royal  Albert  Institution  (1914)  it  is 
stated  that  10  per  cent,  of  the  patients  discharged 
(from  an  aggregate  of  3,433  who  had  been  under 
training)  had  been  rendered  self-supporting,  while 
not  less  than  82  per  cent,  had  shown  evidence  of 
noticeable  improvement.  A  case  is  cited  of  a  boy 
earning  375.  a  week  in  a  Yorkshire  bakery,  and 
another  of  a  patient,  discharged  twenty  years  pre- 
viously, who  gets  3os.  a  week  "  at  a  great  dye-works 
near  Leeds,  and  has  never  lost  a  day's  work,  except 
on  the  occasion  of  a  strike,  with  which  he  had  nothing 
to  do."  It  must  not,  however,  be  imagined  that 
even  the  best  of  the  above  were  in  all  respects  equal 
to  persons  of  average  intelligence.  Some  residual 
peculiarity  usually  remains  to  handicap  the  feeble- 
minded in  the  race  of  life. 

"  It  is  not,  indeed,  to  be  expected  that  without  some 
form  of  tutelage  even  the  trained  defective  can  hold 
his  own  in  the  outside  world,  and  in  the  majority  of 
cases  it  may  be  appropriately  said: 

"  'Tis  not  enough  to  help  the  feeble  up, 
But  to  support  him  after."* 

*  Twenty-seventh  Annual  Report,  Royal  Albert  Asylum,  p.  40. 


228       MENTALLY  DEFICIENT  CHILDREN 


- 

port  is 


There  is  no  doubt,  however,  that  such  support 
rendered  infinitely  easier  by  methodical  training,  and 
the  burden  to  the  friends  much  lighter. 

Before  quoting  further  figures,  it  is  necessary 
explain    that    those    of    different    institutions    an 
societies  can  scarcely  be  compared;  so  much  depen 
on  the  grade  and  type  of  mental  defect  select 
Till  the  passing  of  the  Mental  Deficiency  Act,  191 
we  had  no  generally  accepted  definitions,  far  less  any 
universal  standard.     Under  these  circumstances  sta- 
tistics are  chiefly  of  value  as  showing  the  possibilitii 
and  limitations. 

The  necessity  for  after-care  has  been  establishes 
on  a  priori  grounds;  it  is  interesting  to  see  the  results. 
For  this  purpose  we  will  take  the  records  of  the  Bir- 
mingham After-care  (Education)  Committee,  which 
was  the  first  to  undertake  this  work.  Founded  in 
1901  by  Mrs.  Hume  Pinsent,  it  is  now  able  to  formu- 
late fourteen  years'  experience.  The  last  annual 
report  (dated  June  25,  1915)  states,  that  of  the  1,436 
cases  (876  males,  560  females)  observed — 

495  are  doing  remunerative  work;  of  these  415  are 
earning  wages  which  average  los.  2d.  per  week.  279 
are  males,  earning  from  is.  6d.  to  358.  per  week  (aver- 
age us.  7d.) ;  and  136  are  females  earning  from  35.  to 
2os.  per  week  (average  75.  5d.).  59  youths  are 
soldiers.  18  girls  are  employed  from  home  in  domestic 
work.  13  (8  m.,  5  f.)  work  with  their  relations  at 
home  in  simple  trades,  without  wages.  126  (47  m., 
79  f.)  are  living  at  home  and  doing  unpaid  work. 
41  (17  m.,  24  f .)  were  dismissed  from  special  schools 
as  incapable,  through  physical  or  mental  disability. 
121  (76  m.,  45  f.)  have  been  transferred  to  ordinary 
schools.  5  (4  m.,  I  f.)  have  been  transferred  to 
schools  for  the  deaf;  i  (m.)  to  an  open-air  school; 


RESULTS  AND  CONCLUSIONS  229 

I  (m.)  to  a  private  school;  7  (3  m.,  4  f.)  removed  to 
special  schools  in  other  towns;  18  (16  m.,  2  f.)  are  in 
residential  schools  for  mental  defectives;  81  (42  m., 
39  f.)  are  in  workhouses;  138  (76  m.,  62  f.)  are  in  other 
institutions,  including  91  (54  m.,  37  f.)  in  the  Monyhull 
Colony,  and  17  in  lunatic  asylums.  52  (31  m.,  21  f.) 
have  died,  and  337  (213  m.,  124  f.)  lost  sight  of. 

The  committee  have  frequently  stated  in  their 
reports  that  for  a  large  percentage  of  the  feeble- 
minded permanent  supervision  is  necessary  for  the 
following  reasons: 

"  i.  To  enable  them  to  contribute  to  their  own 
support. 

11  2.  To  save  them  from  harsh  treatment  at  home 
and  in  the  streets. 

"3.  To  prevent  their  becoming  drunkards,  crimi- 
nals, and  prostitutes. 

"4.  To  prevent  their  giving  birth  to  children  who 
can  only  grow  up  to  be  a  burden  to  the  community." 

With  these  statistics  from  Birmingham  we  may 
compare  the  following  extract  from  the  Report  of  the 
After-care  Committee  of  the  London  County  Council 
for  1915,  with  reference  to  those  discharged  from  the 
London  Special  Schools  during  the  previous  three 
years.  This  "  shows  that  from  November,  1910,  to 
November,  1914,  1,448  children  left  the  schools  for 
elder  mentally  defective  children  and  came  under  the 
notice  of  the  association.  Of  these,  812  (55  per  cent.) 
were  in  work  in  October,  1914,  including  72  males 
who  were  serving  with  His  Majesty's  forces.  In  the 
previous  year  it  was  reported  that  72  per  cent,  were 
in  work,  while,  of  the  whole  1,198,  103  were  out  of 
employment,  133  had  been  lost  sight  of,  42  were  in 
institutions,  46  were  not  reported  upon,  and  7 
dead." 


230      MENTALLY  DEFICIENT  CHILDREN 


These  figures,  if  somewhat  more  favourable 
those  from  Birmingham,  extend  over  a  much  briefe 
period,  and,  in  the  long-run,  no  doubt  will  suppor 
the  view  of  the  necessity  of  permanent  care  for  tt 
majority  of  cases.     As  a  matter  of  fact,  the  Birmir 
ham   committee  have  pointed  out  that  much  mor 
satisfactory  returns  are  obtained  when  only  the 
who  have  recently  left  school  are  considered.     The 
said  in  their  1914  report  that  "  it  is  important 
remember  that  the  large  majority  in  employmerj 
are  boys  and  girls  who  have  recently  left  school, 
the   397  in  employment,   only  54  are  over  twenty 
one  years   of  age,   and  only   16  of  these  are   ove 
twenty-five;    but   343    are    of    ages    varying    fror 
fourteen  to  twenty-one  years.     Of  the  latter  group 
the     large     majority     (240)     are     of    ages    vary 
from  fourteen  to  seventeen  years,  as  compared  wit 
103  of   ages   from   eighteen    to    twenty-one.     It 
significant  that  the  age  at  which    there    are  mos 
workers  is  sixteen." 

Mr.  E.  W.  Locke,  Superintendent  of  the  Wester 
Counties  Idiot  Asylum  at  Starcross,  when  giving  ev 
dence  before  the  Royal  Commission  on  the  Care 
Control  of  the  Feeble-minded,  said:  "  I  think  tha 
during  the  last  ten  years  about  forty  children  ha\ 
been  placed  out  in  the  world.     I  have  informatic 
from  about  twenty  of  them ;  several  of  those  are  earn 
ing  their  own  living  independently,  but  they  we 
brilliant  exceptions;  the  others  were  living  at  hon 
and  making  themselves  of  use,  going  out  to  work, 
instance,  in  gardens,  or  doing  needlework  at  home 
and  so  on."     But  he  added,  with  regard  to  those  wt 
are  discharged:  "  They  ought  not  to  go  out  into  tt 
world,  any  of  them,  never  mind  how  competent  the 
are   to   work."     The   subsequent    comment   by   tl: 


RESULTS  AND  CONCLUSIONS  231 

Commissioners  was:  "  This  view  is  held  by  all  our 
witnesses  in  regard  to  this  branch  of  work/'* 

Dr.  E.  B.  Sherlock  has  recently  published  an 
interesting  estimate  of  the  earning  capacity  of 
mental  defectives  employed  at  the  Darenth  Indus- 
trial CxOlony.  He  points  out  that  the  net  profit 
of  the  patients'  work  in  such  an  establishment 
must  needs  be  affected  by  such  considerations  as 
the  following  : — First,  teachers  and  industrial  at- 
tendants command  higher  salaries  than  ordinary 
attendants ;  '  secondly,  the  working  patients  require 
better  feeding  than  others;  and  finally,  their  hours 
of  labour  are  necessarily  shorter  than  those  current 
in  the  various  trades,  and  these  he  estimates  at 
35  per  week.  He  proceeds : 

"  In  order  to  obtain  information  as  to  the  actual 
earning  powers  of  the  patients  at  Darenth  an  inquiry 
has  been  made  into  the  capacity  of  each  individual 
over  the  age  of  fourteen  years,  that  age  being  taken 
as  the  one  at  which  persons  not  mentally  defective 
and  of  the  same  social  class  as  the  patients  might  be 
expected  to  contribute  something  towards  their  own 
maintenance.  To  arrive  at  anything  like  a  satis- 
factory valuation  has  proved  to  be  a  matter  of 
extreme  difficulty,  and  the  results  obtained  are 
incomplete  and  probably  vitiated  by  numerous 
errors.  Nevertheless,  they  appear  to  have  suffi- 
cient interest  to  make  the  publication  of  them 
desirable. 

"  For  imbeciles,  the  average  earning  capacity 
per  week  in  the  following  industries  was  : — Males: 
Mat -making,  35.  2d. ;  brush-making,  35.  iod.;  boot- 
making,  5s.  8d;  tailoring,  6s.;  upholstering,  75.; 

*  Report  of  the  Royal  Commission  on  the  Care  and  Control 
of  the  Feeble-minded,  vol.  viii.,  p.  159. 


232      MENTALLY  DEFICIENT  CHILDREN 

basket-making,  75.  2d. ;  carpentry,  95.  3d. ;  painting, 
6s.;  printing,  75.;  book-binding,  45.  gd. ;  metal- 
working,  8s.  3d.;  wood-chopping,  2s.  6d.;  carting, 
2s.;  school  industries,  is.;  odd  jobs,  is. 

"  For  females  the  average  earning  capacity  was  : — 
Needlework,  is.  8d. ;  upholstering,  2s.  90!.;  bag- 
making,  9|d. ;  machine  knitting,  75.  id.;  brush- 
making,  is.  4d. ;  rug-making,  45. ;  school  industries, 
is.  id. 

"  For  the  feeble-minded  males  the  average  earning 
capacity  was: — Farming,  45.  9d. ;  boot-making, 
6s.  3d.;  tailoring,  5s.  4d. ;  cord-making,  is.  3d.; 
laundry  work,  5s. 

"  For  feeble-minded  females  the  average  earning 
capacity  was: — Needlework,  is.  4d.;  laundry  work, 
2s.  id.;  machine  and  other  knitting,  45.  6d." 

With  regard  to  American  experiences,  we  will  quote 
from  a  paper  by  Dr.  Walter  E.  Fernald,  of  Waver- 
ley.  He  says:  "Each  year  a  certain  number  of 
persons  (trained  in  industrial  work)  go  out  from  these 
institutions  [for  the  feeble-minded],  and  lead  useful, 
harmless  lives.  Some  of  the  institutions  where  only 
the  brightest  class  of  imbeciles  are  received,  and 
where  the  system  of  industrial  training  has  been  very 
carefully  carried  out,  report  that  from  20  to  30  per 
cent,  of  the  pupils  are  discharged  as  absolutely  self- 
supporting.  In  other  institutions,  where  the  lower- 
grade  cases  are  received,  the  percentage  of  cases  so 
discharged  is  considerably  less.  It  is  safe  to  say  that 
not  over  10  to  15  per  cent,  of  our  inmates  can  be  made 
self-supporting,  in  the  sense  of  going  out  into  the  com- 
munity and  securing  and  retaining  a  situation,  and 
prudently  spending  their  earnings.  With  all  our 
training  we  cannot  give  our  pupils  that  indispensable 
something  known  as  good,  plain  common-sense.  The 


RESULTS  AND  CONCLUSIONS  233 

amount  and  value  of  their  labour  depend  upon  the 
amount  of  oversight  and  supervision  practicable. 
But  it  is  safe  to  say  that  over  50  per  cent,  of  the  adults 
of  the  higher  grade  who  have  been  under  training 
from  childhood  are  capable,  under  intelligent  super- 
vision, of  doing  a  sufficient  amount  of  work  to  pay  for 
the  actual  cost  of  their  support,  whether  in  an  insti- 
tution or  at  home." 

In  support  of  the  claim  for  after-care,  and  as  an 
embodiment  of  the  most  recent  ideas  in  America  on 
this  question,  we  cannot  do  better  than  quote  from 
the  conclusions  summarised  by  the  members  of  the 
Royal  Commisson  on  the  Care  and  Control  of  the 
Feeble-minded  who  visited  that  country:  . 

"  Most  of  the  American  institutions  were  started  as 
schools  for  feeble-minded  children,  under  the  idea  which 
prevailed  that  a  large  number  of  these  could  be  educated 
so  as  to  be  able  to  take  their  place  in  the  world  alongside 
of  their  normal  brothers  and  sisters.  This  idea  has  been 
modified  by  experience,  and  now  it  is  the  opinion  of 
those  whom  we  consulted  that  it  is  only  a  very  small 
fraction  of  the  feeble-minded  who  can  stand  alone,  how- 
ever excellent  their  education  may  have  been.  Two 
results  flow  from  this :  Firstly,  although  in  some  places 
the  system  of  education  still  follows  on  the  lines  of  that 
given  in  schools  for  normal  children,  in  those  institutions 
which  appeared  to  us  to  be  the  most  scientifically 
organised  there  is  now  a  tendency  to  limit  the  instruc- 
tion to  such  manual  work  as  the  feeble-minded  are  found 
able  to  perform,  and  as  will  afford  them  occupation  and 
happiness  as  inmates  of  permanent  working  homes. 
Secondly,  the  opinion  'has  now  become  general  that  the 
provision  of  schools  for  feeble-minded  children  must  be 
accompanied  by  permanent  homes  for  adults.  The 
present  schools  have  become  congested  with  adults  who 
have  grown  up  in  the  school,  and  whom  the  managers 
"  ive  felt  constrained  to  retain  there  for  fear  of  the 


234     MENTALLY  DEFICIENT  CHILDREN 

disasters  which  would  have  fallen  upon  the  adolescent  if 
turned  adrift  into  the  world.  Hence,  those  interested 
in  the  American  institutions  have  induced  the  State 
Legislatures  to  allow  of  the  establishment  of  depart- 
ments or  branches  for  adults,  into  which  they  can  draft 
the  children  who  have  passed  school  age,  and  also  admit 
from  outside  feeble-minded  adult  men  and  women  whom 
the  Poor  Law  or  other  public  authority  may  think 
require  the  protection  of  a  home.  Expert  opinion  con- 
demns as  ineffective  and  wasteful  an  institution  which 
lacks  a  custodial  department  or  colony  or  other  annexe 
for  adults." 

Nevertheless,  it  is  not  quite  fair  to  conclude  that 
the  benefits  of  training  institutions,  as  at  present 
organised,  are  merely  to  be  measured  by  appraising- 
the  proportion  of  those  sent  out  able  to  earn  their 
own  living.  This,  of  course,  is  a  positive  gain,  but 
there  are  benefits,  which  we  may  call  negative,  hardly 
less  appreciated  by  those  on  whom  the  care  of  the 
mentally  deficient  falls.  That  a  child  should  no 
longer  be  uncleanly,  mischievous,  or  destructive,  in 
habits;  that  it  should  cease  to  disturb  the  peace  of 
the  household  by  discordant  cries,  and  by  untimely 
wanderings,  are  points  which  parents  thankfully 
recognise;  and  if,  in  addition,  it  can  be  taught  to 
undress  and  dress  itself,  to  feed  itself,  and  to  behave 
with  propriety,  these  results  are  by  no  means  despic- 
able, even  from  the  economical  point  of  view.  It  must 
not  be  forgotten  that  the  charge  of  an  untrained  idiot 
at  home  usually  monopolises  the  time  of  one  of  the 
older  members  of  the  family,  who  is  thus  prevented 
from  earning  wages;  and  without  judicious  training 
and  discipline  deterioration  is  pretty  sure  to  occur. 
Even  in  the  best-regulated  families  the  care  of  a 
defective  child  is  a  constant  anxiety;  how  much 
more  in  the  labourer's  cottage,  where  oftentimes  only 


RESULTS  AND  CONCLUSIONS  235 

casual  attention  can  be  given  to  it  ?  The  relief  to 
parents  afforded  by  Institution  treatment  is  well  illus- 
trated in  the  Report  for  1894  of  the  superintendent 
of  the  Eastern  Counties  Asylum.  He  gives  a  striking 
example  of  a  mischievous  imbecile,  who  "  describes 
with  great  glee  how  (before  admission)  he  was  left  to 
mind  the  baby,  and  blacked  its  face  all  over  with  soot, 
so  that  when  his  mother  returned  she  might  think 
she  had  a  black  baby;  how  his  little  sister  wanted 
some  water,  and  he  told  her  to  drink  out  of  the  kettle 
on  the  fire,  by  which  she  nearly  lost  her  life;  and  how 
he  was  turned  out  of  the  Parish  Church,  during 
service,  for  pricking  a  boy  with  a  pin,  so  that  he 
yelled  out  and  disturbed  the  whole  congrega- 
tion !" 

For  improved  cases,  able  to  take  situations  on 
leaving  Training  Institutions,  it  seems  very  desirable 
that  there  should  be  established  in  all  parts  of  the 
county  some  organisation  of  philanthropic  persons 
willing  to  exercise  a  friendly  supervision,  such  as  the 
After-care  Committees  in  London,  Birmingham,  and 
other  English  centres,  and  certain  Continental  cities.* 
Since  the  passing  of  the  Mental  Deficiency  Act,  much 
has  been  accomplished  in  this  direction  by  the  estab- 
lishment of  the  Central  Association  for  the  Care  of 
the  Mentally  Defective,  under  the  able  chairmanship 
of  Mr.  Leslie  Scott,  K.C.,  M.P.,  with  Miss  Evelyn 
Fox  as  Honorary  Secretary.  This  association, 
which  has  offices  at  Queen  Anne's  Chambers,  Tothill 
Street,  Westminster,  has  co-ordinated  several  of  the 
existing  After-care  Societies,  and  stimulated  the 
formation  of  others.  Through  its  agency,  overlapping 
in  this  charitable  work  will  be  prevented,  new  workers 

*  Treatment  of  Feeble-minded  :  Question  of  After-care, 
Shu  ttleworth,  1904. 


236      MENTALLY  DEFICIENT  CHILDREN 

will  have  the  benefit  of  the  experience  that  has  been 
gained,  and  all  reports  will  be  kept  on  similar  lines. 
Recently  it  has  developed  other  useful  activities  in  the 
direction  of  providing  training  for  special  teachers. 
Unfortunately,  while  the  Mental  Deficiency  Act  in 
Section  48  encourages  the  formation  of    After-care 
Committees,  and  provides  them  with  money  from 
Parliamentary  grant  for  the  purpose  of  assisting  and 
supervising   defectives,    it   does   not   make   this   an 
obligatory  duty.      When  a  defective  is  withdrawn 
or   discharged  from   a  special  school  on  or  before 
attaining    the    age    of    sixteen,    without   a    notice 
being    sent    by    the    local    education    authority   to 
the    local    authority    under    the    Act    that    he    is 
an  imbecile  or  detrimental  to  the  other  children  in 
school,  or  that  it  would  be  to  his  benefit  that  he 
should  be  sent  to   an  institution  or  placed  under 
guardianship,  there  is  no  statutory  obligation  for  his 
supervision.     It  is,  however,  only  fair  to  say  that  we 
have  known  some  remarkable  instances  of  permanent 
improvement  resulting  from  training.    A  former  insti- 
tution pupil,  an  example  of  the  class  now  designated 
"  feeble-minded "    as    distinguished    from    imbecile, 
though  for  a  period  an  inmate  of  the  Royal  Albert 
Asylum,  became,  under  instruction,  an  expert  joiner, 
and  (what  was  even  more  remarkable)  from  being  a 
very  imp  of  mischief  grew  up  into  a  well-conducted, 
self-reliant  youth,  and  ultimately  emigrated  to  one 
of  our  colonies.     When  last  heard  of,  he  was  practising 
his  trade  in  a  leading  city,   and  in  a  letter  home 
reported  himself  as  doing  well,  business  being  brisk 
in  consequence  of  a  conflagration  which  had  recently 
occurred  !     In  another  instance  of  mild  defect,  the 
result  of  an  injury  in  infancy,  treated  at  the  Royal 
Albert  Asylum  with  great  benefit,  a  girl,  after  dis- 


RESULTS  AND  CONCLUSIONS  237 

charge,  got  respectably  married,  and  is  said  to  be  an 
excellent  housewife. 

It  is  remarkable  that  of  nearly  a  thousand  dis- 
charged patients  who  had  passed  under  observation 
at  the  Royal  Albert  Asylum  the  two  just  mentioned 
are  the  only  instances  in  which  we  have  known  mar- 
riages occur.  It  has,  indeed,  been  urged  as  an  objec- 
tion to  educating  mentally  deficient  children,  and 
fitting  them  for  work  in  the  world,  that  they  would  be 
thereby  encouraged  to  marry,  and,  in  consequence, 
there  would  be  a  risk  of  multiplying  mental  defect  in 
the  progeny.  Our  experience,  however,  does  not 
altogether  support  this  view.  It  is  quite  true  that 
the  mentally  defective,  when  left  to  themselves,  do 
produce,  both  in  and  out  of  wedlock,  a  considerable 
number  of  children,  many  of  whom  exhibit  the  same 
weakness  as  their  parents.  Dr.  Potts,  when  working 
at  Stoke-on-Trent  for  the  Royal  Commission  on  the 
Care  and  Control  of  the  Feeble-minded,  collected  clear 
evidence  on  this  point.  It  does  not,  however,  hold 
good  to  the  same  extent  in  the  case  of  those  who  have 
had  judicious  training  in  such  an  institution  as  the 
Royal  Albert  Asylum.  In  one  case,  that  of  a  youth 
who,  after  a  long  period  of  institution  training,  had 
become  an  industrious  labourer,  and  was  earning 
eighteen  shillings  a  week,  we  ventured  to  ventilate 
the  subject  of  marriage.  The  young  man  had  been 
telling  us  how,  in  addition  to  paying  for  his  board,  he 
had  been  able  to  accumulate  a  fair  amount  in  the  Post- 
Office  Savings  Bank.  "  Well/'  we  suggested  tenta- 
tively, "  perhaps  you  are  saving  up  against  getting 
married/'  "  Nay,  nay,  doctor,"  was  the  reply;  "  it's 
hard  enough  for  a  feller  to  keep  hisself,  let  alone 
bothering  with  a  girl !"  Such  philosophy  as  this  is 
rarely  met  with  in  the  social  class  to  which  this  youth 


238      MENTALLY  DEFICIENT  CHILDREN 


belongs,  or  we  should  hear  less  of  improvident  mar- 
riages. The  effect  of  judicious  training  seems  to  be 
to  impress  upon  the  improved  imbecile  that  he  is  not 
quite  like  other  men,  and  must  not  undertake  the 
responsibilities  of  married  life.  Certainly,  the  net 
result  of  training  is  to  diminish  the  risk  of  transmit- 
ting the  evil  to  another  generation,  inasmuch  as  moral 
principles  are  instilled  which  have  a  restraining  influ- 
ence on  conduct.  Moreover,  the  very  fact  of  healthy 
occupation  tends  to  keep  in  check  the  animal  passions, 
which  are  apt  to  run  riot  when  the  adolescent  imbecile 
is  unemployed.  This  is  one,  amongst  other  reasons, 
for  the  establishment  of  permanent  industrial  homes 
like  those  belonging  and  affiliated  to  the  National 
Association  for  the  Feeble-minded. 

Considerable  experience  in  the  training  of  mentally 
peculiar  children  of  the  well-to-do  class  has  convinced 
us  of  the  benefit  resulting  from  appropriate  education 
commenced  at  an  early  age,  if  due  care  be  taken  to 
provide  them  after  school  life  with  occupations  suit- 
able to  their  capacities  under  some  degree  of  judicious 
supervision.  We  can  point  to  cases  in  which  artistic 
and  musical  talents  have  been  developed  in  such  a 
way  as  to  render  subsequent  home  life  resourceful 
and  no  longer  a  burden  to  the  relatives,  and  to  others 
in  which  occupation  in  such  pursuits  as  horticulture 
and  farming  has  furnished  a  useful  career. 

The  history  of  legislation  for  the  benefit  of  educable 
feeble-minded  as  distinguished  from  imbecile  children 
has  already  been  given,  and  we  have  now  had  more 
than  twenty  years'  practical  experience  of  special 
classes  for  exceptional  children  in  elementary  day- 
schools.  We  think  we  can  fairly  claim  that,  where 
tried,  they  have  filled  up  a  lacuna  in  the  scheme  of 
national  education.  In  the  words  of  the  Report  of 


RESU  ITS  AND  CONCLUSIONS  239 

the  Royal  Commission  on  the  Care  and  Control  of  the 
Feeble-minded : 

"  It  [i.e.,  the  establishment  of  special  schools]  gave 
to  those  interested  in  education  the  first  opportunity 
of  trying  what  could  be  done  for  these  children  on  day- 
school  lines  and  under  a  special  curriculum.  Whether 
the  number  of  those  who,  when  they  left  school,  could 
materially  support  themselves  were  few  or  many,  it 
helped  to  make  the  larger  number  of  the  children  cleaner 
in  person  and  habits,  more  orderly  and  more  moral; 
it  did  this  where  the  parents  cared  for  their  children  and 
wished  to  do  the  best  for  them,  and  it  did  it,  as  far  as 
might  be,  where  the  parents  were  careless  and  incon- 
siderate of  their  children's  welfare.  The  scrutiny  of  the 
lives  and  mental  condition  of  children,  made  in  conse- 
quence of  the  investigations  of  Dr.  Francis  Warner, 
Dr.  Shuttleworth,  and  others,  led  to  the  passing  of  the 
Act;  and  the  Act  itself  has  been  instrumental  in  pro- 
ducing still  further  inquiries  of  the  same  nature." 

The  Report  then  goes  on  to  show  that  it  might  not 
be  altogether  wise  to  continue  simply  on  the  same 
lines,  and  merely  make  the  Elementary  Education 
(Defective  and  Epileptic  Children)  Act,  1899,  com- 
pulsory. It  explains  that  the  demand  which  the  Act 
first  created  has  assumed  larger  proportions. 

"  Schooling*  in  personal  habits  was  found  to  be  the 
first  step  in  education.  Then,  more  and  more,  it  was 
made  evident  that  the  intelligence  was  roused  through 
the  hands  and  eyes  working  together  in  making  or  doing 
some  actual  thing,  rather  than  by  the  secondary  and 
more  abstract  accomplishments  of  reading,  writing,  and 
arithmetic.  This  suggested  great  changes  in  teaching. 
And  now,  in  the  opinion  of  many,  the  simple  '  occupa- 
tions '  of  the  earliest  years  of  schooling  should  develop 
into  systematic  industrial  teaching,  while  the '  scholastic  ' 

*  Report  of  Royal  Commission  on  Care  and  Control  of  Feeble- 
minded, p,  103,  par.  338. 


240      MENTALLY  DEFICIENT  CHILDREN 

teaching  should  become  entirely  subordinate,  and, 
indeed,  in  some  cases  should  be  discontinued.  But, 
as  we  have  seen,  criticism  has  gone  farther  still. 
Analysis  has  shown  that  the  special  school  by  itself  is 
largely  unserviceable,  from  the  point  of  view  of  the 
after-life  of  the  child.  The  feeble-minded  child  can, 
in  the  main,  become  only  a  feeble-minded  adult,  edu- 
cated into  a  rather  better  routine  of  thought  and  habit. 
If  special  education  is  required  on  his  behalf  in  his  school- 
days, special  care  will  probably  be  necessary  for  him 
when  he  has  left  school;  and,  moreover,  later  on  in  life. 
All  this,  by  degrees,  the  Act  of  1899  has  enabled  many 
to  learn." 

Hence  the  idea  that 

"  either  the  special  classes  will  become  classes  for  the 
dull  and  backward,  from  which  the  feeble-minded,  except, 
possibly,  those  who  are  of  the  very  highest  type,  will, 
by  degrees,  be  excluded;  or,  as  at  Leicester,  new  classes 
for  the  backward  will  be  started,  and  the  present  classes 
for  the  feeble-minded  will  be  continued  as  a  kind  of  lowest 
class  of  all,  and  will  be  supplemented  to  a  much  larger 
extent  by  institutional  care  of  some  kind.  According  to 
our  judgment,  this  '  backward '  class  should  remain 
under  the  direct  control  of  the  education  authorities, 
for  the  children  in  them  could  not  be  certified;  while 
the  children  who  are  or  may  become  certifiable  as 
mentally  defective  should  fall  within  the  province  of  the 
Committee  for  the  Care  of  the  Mentally  Defective,  who, 
either  directly  or  by  contract  with  the  education  author- 
ities, should  provide  for  them/' 

In  a  paper  on  the  Result  of  Special  School  Educa- 
tion read  at  the  Conference  of  the  National  Special 
Schools  Union  in  Birmingham  in  1910,  Mrs.  Hume 
Pinsent  said,  in  regard  to  the  children  who  remain  in 
special,  schools,  that  "  it  is  quite  exceptional  for  any 
of  them  to  reach  a  higher  educational  position  than 
that  attained  in  Standard  II.  This  means  that  at 


RESULTS  AND  CONCLUSIONS  241 

sixteen  the  best  of  them  will  be  able  to  read  and 
calculate  to  about  the  same  extent  as  a  normal  child 
of  eight  or  nine.  The  numbers  who  attain  to  Standard 
II.  are  variously  stated  by  witnesses  as  from  40  to 
58  per  cent.,  at  the  best  only  about  half  the  total 
number."  "  If  it  is  a  question  of  pleasure  or  profit 
to  be  obtained  from  reading,  I  am  afraid  we  cannot 
flatter  ourselves  that  special  school  teaching  confers 
this  benefit  on  the  mentally  defective ;  for  to  read  for 
pleasure  after  school  age  a  far  greater  ease  and  fluency 
must  be  obtained  than  is  represented  by  Standard  II. 
Only  about  half  get  even  as  far  as  this."  After 
pleading  for  more  manual  work,  Mrs.  Pinsent  goes  on 
to  say  that,  "  Just  as  their  manual  work,  though  fair 
in  its  results  when  done  under  supervision,  has  no 
value  in  the  open  market,  so  their  frail  morality,  when 
severed  from  the  ever-present  sanction  of  the  teacher, 
falls  to  pieces  on  contact  with  the  outside  world,  and 
succumbs  to  every  temptation/' 

As  regards  the  results  attained  in  the  Residential 
Homes  charitably  founded  for  feeble-minded  girls 
beyond  school  age,  it  must  suffice  to  say  that  in  some 
of  those  longest  established  an  appreciable  portion  of 
income  is  derived  from  payments  for  the  work  of  the 
inmates.  Thus  it  has  been  calculated  that  at  the 
Homes  of  Industry,  established  near  Birmingham  in 
1892  by  the  late  Miss  Stacey,  for  feeble-minded  girls, 
more  than  2s.  per  head  per  week  is  on  the  average  made 
by  the  labour  of  the  45  inmates  in  aid  of  maintenance, 
the  weekly  rate  for  which  is  about  8s.  gd.  It  was 
stated,  however,  in  the  evidence  before  the  Royal 
Commission,  that,  although  these  Homes  are  mainly 
custodial,  out  of  101  discharged  for  various  reasons, 
not  more  than  3  were  really  fit  to  return  to  ordinary 
life.  The  industries  carried  on  in  the  Homes  consist 

16 


242      MENTALLY  DEFICIENT  CHILDREN 


principally  of  laundry  work  and  of  mat  and  rug 
making. 

The  results  obtained  by  more  recent  homes,  if  less 
successful  financially,  are  distinctly  encouraging. 
Thus  the  National  Association  Report  of  Alexander 
House  (a  working  home  for  19  girls  over  fourteen 
at  Hammersmith),  after  eight  years'  working,  stated: 
"  There  are  now  8  girls  in  service,  who  are  regularly 
visited.  Of  these,  4  are  going  on  well ;  the  others  leave 
their  situations  frequently,  their  mental  deficiencies 
making  them  unable  to  work  steadily  for  any  length 
of  time."  Further  experience  has,  however,  proved 
the  need  for  permanent  care  in  the  majority  of  cases. 

Did  space  permit,  it  would  be  easy  to  give  proofs 
of  individual  improvement  resulting  from  these  and 
similar  homes  (of  which  a  list  will  be  found  in 
Appendix  A) ;  but  for  particulars  the  reader  is 
referred  to  the  Reports  of  the  Homes,  and  to  the 
publications  on  After-care  of  the  National  Associa- 
tion for  the  Feeble-minded,  to  be  obtained  at  their 
offices,  72,  Denison  House,  Vauxhall  Bridge  Road, 
S.W.  As  the  result  of  the  passing  of  the  Mental 
Deficiency  Act,  it  is  to  be  hoped  that  all  defectives 
over  sixteen  who  are  without  proper  provision,  and 
are  a  source  of  danger  to  themselves  or  the  community, 
will  be  kindly  taken  care  of  in  such  institutions  as  we 
have  described. 

Objection  has  sometimes  been  taken  to  the  benevo- 
lent efforts  of  the  last  seventy  or  eighty  years  in 
favour  of  the  mentally  deficient,  that  they  are  an- 
tagonistic to  Nature's  law,  expressed  in  the  formula, 
"  The  survival  of  the  fittest."  We  would  submit, 
however,  that  the  reclamation  of  these  outcasts,  and 
more  especially  the  "  setting  of  the  solitary  in 
families  "  (i.e.,  in  institutions  and  colonies),  has  not 


RESULTS  AND  CONCLUSIONS  243 


necessarily  been  inconsistent  with  our  duties  towards 
posterity,  for  it  has  aroused  a  scientific  interest  in 
questions  of  heredity  previously  imperfectly  under- 
stood. As  Dr.  Saleeby  well  puts  it  in  his  work  on 
"  Parenthood  and  Race  Culture/'  "  the  ideal  of 
eugenics  is  to  abolish  the  brutal  elements  of  the 
struggle  for  existence,  whilst  gaining  its  great  end." 
Let  us  by  all  means  adopt  every  reasonable  measure 
to  prevent  the  perpetuation  of  the  evil,  but  in  the 
meantime  we  are  responsible  for  those  weaklings  we 
have  allowed  to  be  born  as  fellow-members  of  the 
human  family.  It  is  not  denied  that  individual 
lives,  which,  if  left  to  themselves,  would  probably  be 
extinguished  in  the  struggle  for  existence,  are  by 
fostering  care  prolonged,  perhaps  contrary  to  the 
rigid  principles  of  social  economy.  It  may,  indeed, 
be  admitted  that  much  that  has  been  done  for  the 
idiot  and  imbecile,  and  even  for  the  feeble-minded, 
can  only  be  justified  on  the  ground  of  that  quality  of 
mercy  which  is  "  nobility's  true  badge,"  and  "  blesseth 
him  that  gives  and  him  that  takes."  May  we  not 
indeed  in  this,  as  in  much  other  philanthropic  work 
which  tends  to  soften  the  asperities  of  Nature's  laws, 
endeavour  humbly  to  follow  in  the  footsteps  of  Him 
of  whom  it  was  foretold  that  "  A  bruised  reed  shall 
He  not  break,  and  the  smoking  flax  shall  He  not 
quench  "  ? 

LATEAT  SCINTILLULA  FORSAN  ! 


APPENDIX   A 
MENTAL  DEFICIENCY  ACTS,  1913. 


(List  kindly  supplied  by  Board  of  Control,  February,  1916.) 


ENGLAND  AND  WALES. 
Certified  Institutions. 

Figures  indicate  number  admissible, 
m.,  Males  only;  /.,  Females  only;  m.f.,  Males  and  Females. 

BERKSHIRE. 

/.  CUMNOR  RISE,  CUMNOR — Hon.  Sec.,  Hon.  Pamela  Bruce. 
Radcliffe  House,  St.  Giles,  Oxford;  Supt.,  Miss  Haigh.  (22) 

CHESHIRE. 

m.f.  SANDLEBRIDGE,  ALDERLEY  EDGE — Hon.  Sec.,  ].  S. 
Walker,  54,  Kenwood  Road,  Stretford,  Manchester.  Supt., 
Miss  Grace  Wyatt.  (275) 

/.  ASHTON  HOUSE  (SEASIDE  LAUNDRY  HOME),  PARKGATE- 
Hon.  Sec.,  Miss  J.  M.  Grayson,  29  Ullett  Road,  Liverpool; 
Supt.,  Mrs.  Dennis.  (20 

CUMBERLAND. 

m.f.  DURRAN  HILL  HOUSE,  CARLISLE — Sec.,  T.  W.  Hunter, 

Archbishop's  House,  Victoria  Street,  London,  S.W. ;  Supt., 

Sister  Ethelburga  Ring.  (65 

244 


APPENDIX  A  245 


DERBY. 

/.  WHITTINGTON  HALL  (MIDLAND  COUNTIES  INSTITUTION), 
CHESTERFIELD — Warden,  Rev.  H.  N.  Burden,  14,  Howick 
Place,  Victoria  Street,  London,  S.W.;  Supt.,  Miss  Smith. 

(320) 

m.  HOPWELL  HALL  COLONY,  NEAR  DERBY — Hon.  Sec.,  Mrs. 
Kipping,  40,  Magdala  Road,  Nottingham;  Supt.,  Mrs.  H. 
Swinburne.  (50) 

DEVON. 

m.f.  WESTERN  COUNTIES  INSTITUTION,  STARCROSS,  NEAR 
EXETER — Supt.  and  Sec.,  E.  W.  Locke.  (336) 

DURHAM. 

m.  MONKTON  HALL  HOME  FOR  LADS,  MONKTON,  JARROW-ON- 
TYNE — Hon.  Sec.,  Dr.  Ethel  Williams,  3,  Osborne  Terrace, 
Newcastle-upon-Tyne ;  Supt.,  Mr.  Piggott.  (42) 

ESSEX 

m.f.  ROYAL  EASTERN  COUNTIES  INSTITUTION  FOR  IDIOTS, 
COLCHESTER — Supt.,  F.  Douglas  Turner,  M.B.  Sec.,  A. 
Turner.  (512) 

m.  THURLBY  HOUSE  SCHOOL,  WOODFORD  BRIDGE — Sec.,  T. 
W.  Hunter,  Archbishop's  House,  Westminster,  London, 
S.W. ;  Supt.,  Miss  Mary  Ryan.  (40) 

/.  ETLOE  HOUSE,  CHURCH  ROAD,  LEYTON,  N.E. — Supt., 
Sister  Susan  O'Reilly.  (122) 

m.  CO-OPERATIVE  SANATORIUM  (NEW  LODGE,  LEON  HOUSE, 
THE  HOMESTEAD  AND  ST.  KEVERNE),  BILLERICAY — Sec., 
Thos.  Wm.  Edwards,  New  Lodge,  Billericay;  Supt.,  T.  W. 
Edv/ards.  (56) 

GLOUCESTER. 

/.  ST.  MARY'S  HOME,  PAINSWICK,  NEAR  STROUD— Hon.  Sec., 

Miss   Wemyss,   Washwell  House,   Painswick ;    Supt.,   Mrs. 

•    Oddy.  (26) 


246      MENTALLY  DEFICIENT  CHILDREN 

m.f.  STOKE  PARK,  BRISTOL  (with  ancillary  premises),  ROYAL 
VICTORIA  HOME,  HORFIELD,  BRISTOL  ;  CLEVEDON  HALL, 
CLEVEDON  ;  and  BEECH  HOUSE — Warden,  Rev.  H.  N. 
Burden,  14,  Howick  Place,  Victoria  Street,  London,  S.W.; 
Supt.,  Miss  Gladys  Williams.  (940) 

/.  CHASEFIELD  LAUNDRY  HOME,  874,  FISHPONDS  ROAD, 
FISHPONDS,  BRISTOL — Hon.  Sees.,  Miss  Alice  Mary  Laving- 
ton  and  Miss  Clara  E.  Sheppard,  Stoberry  Lodge,  1 8,  Ash- 
grove  Road,  Redland,  Bristol;  Supt.,  Miss  Ada  Brett.  (38) 

HAMPSHIRE. 

/.  ST.  MARY'S  HOME,  ALTON  (Wantage  Sisters) — Supt.,  Sister 
Rachel.  t45) 

HERTS. 

m.f.  ST.  ELIZABETH'S  HOME  FOR  EPILEPTICS,  MUCH  HADHAM 
— Sec.,  T.  W.  Hunter,  Archbishop's  House,  Westminster, 
S.W.;  Supt.,  Sister  Mary  Edmund.  (136) 


KENT. 

m.f.  PRINCESS  CHRISTIAN'S  FARM  COLONY,  HILDENBORO' — 
Part  certified.  Part  approved.  Applications  to  Miss 
Kirby,  Secretary  National  Association  for  Feeble-minded, 
Denison  House,  Vauxhall  Bridge  Road,  S.W.—Supt.,  Miss 
E.  J.  Price.  (102) 

LANCASHIRE. 

m.f.  ROYAL  ALBERT  INSTITUTION,  LANCASTER — Supt.,  Dr. 
W.  H.  Coupland;  Sec.,  S.  Keir.  (750) 

/.  45,  WEBSTER  STREET,  GREENHEYS,  MANCHESTER — Hon. 
Sec.,  Miss  A.  H.  Macalpine,  164,  Denmark  Road,  Moss  Side, 
Manchester;  Supt.,  Mrs.  Collier.  (16) 

m.f.  PONTVILLE  SPECIAL  SCHOOL,  AUGHTON,  ORMSKIRK — 
Hon.  Sec.,  Very  Rev.  W.  Canon  Pinnington,  The  Presbytery, 
Great  Mersey  Street,  Liverpool;  Supt.,  Sister  M.  A.  Driscoll. 


APPENDIX  A  247 

/.  DOVECOT  (HORTICULTURAL  SCHOOL),  KNOTTY  ASH,  LIVER- 
POOL —  Hon.  Sec.,  Miss  J.  M.  Gray  son,  29,  Ullett  Road, 
Liverpool;  Supt.,  Miss  F,  C.  Eyre.  (55) 

/.  ADCOTE  (LAUNDRY  AND  TRAINING  HOME),  PILCH  LANE, 
KNOTTY  ASH,  LIVERPOOL  —  Hon.  Sec.,  Miss  J.  M.  Grayson, 
29,  Ullett  Road,  Liverpool;  Supt.,  Miss  L.  Foster.  (19) 

/.  BROCKHALL,  LANGHO,  NEAR  BLACKBURN  —  Clerk,  Lancashire 
Asylums  Board,  Sir  Harcourt  E.  Clare;  Supt.,  Dr.  F.  Gill. 


LONDON. 

/.  41,  DOWNS  ROAD,  CLAPTON,  N.E.  —  Sec.,  Miss  C.  Tozer, 
39,  Downs  Road,  Clapton,  N.E.;  Supt.,  Miss  Main.  (Girls 
over  16.)  (25) 

/.  46-48,  PEMBURY  ROAD,  CLAPTON,  N.E.  —  Sec.,  Miss  C.  Tozer, 
39,  Downs  Road,  Clapton,  N.E.—  Supt.,  Miss  E.  Allen. 
(Girls  over  16.)  (30) 

/.  39,  DOWNS  ROAD,  CLAPTON,  N.E.  —  Sec.,  Miss  C.  Tozer,  39, 
Downs  Road,  Clapton,  N.E.  —  Supt.,  Miss  Aubery.  (Girls 
over  8.)  (25) 

/.  CLIFTON  HOUSE,  127,  UXBRIDGE  ROAD,  SHEPHERD'S  BUSH, 
W.  —  Sec.,  Miss  Pierce,  Church  Army  Rescue  Homes; 
Supt.,  Miss  Margaret  Fanny  Pearne.  (40) 

/.  SPRINGFIELD  LODGE,  GROVE  HILL  ROAD,  DENMARK  HILL, 
S.E.  —  Sec.,  Miss  J.  A.  Cox,  Salvation  Army  Social  Work, 
280,  Mare  Street,  N.E.;  Supt.,  Miss  Annie  Salt.  (28) 


MIDDLESEX. 

/.  CRATHORNE,  OAK  LANE,  EAST  FINCHLEY,  N.  —  Hon.  Sec., 
Mrs.  Moss-Blundell,  7,  North  Grove,  Highgate,  N.;  Supt., 
Mrs.  Morfee.  Including  mothers  and  children.  (32) 

m.  BRAMLEY  HOUSE,  GORDON  HILL,  ENFIELD.  —  Clerk,  H.  S. 
Freeman.  (Middlesex  County  Council.)  (44) 


248      MENTALLY  DEFICIENT  CHILDREN 


NORFOLK. 

m.  GUILTCROSS  (EASTERN  COUNTIES  INSTITUTION),  EAST 
MARLING. — Warden,  Rev.  H.  N.  Burden,  14,  Howick  Place, 
Victoria  Street,  London,  S.W. — Supt.,  Dr.  Manning.  (410) 

OXFORD. 

/.  ST.  PETER  LE  BAILEY  RECTORY,  NEW  INN,  HALL  STREET, 
OXFORD  (BRANCH  OF  CUMNOR  RISE,  CUMNOR). — Sec.,  Hon. 
Pamela  Bruce;  Supt.,  Miss  Haigh.  (24) 

SOMERSET. 

m.f.  ROCK  HALL  HOUSE  (MAGDALEN  HOSPITAL  SCHOOL), 
COMBE  DOWN,  BATH  (Bath  County  Borough). — Clerk,  Bath 
Municipal  Charity  Trustees,  E.  Newton  Fuller,  i,  Queen 
Square,  Bath. — Supt.,  Miss  J.  Quinton.  (34) 

SUFFOLK. 

/.  ST.  JOSEPH'S  HOME,  THE  CROFT,  SUDBURY. — Supt.,  Sister 
M.  Murray.  (15) 

SURREY. 

m.f.  THE  ROYAL  EARLSWOOD  INSTITUTION  FOR  MENTAL  DP- 
FECTIVES,  REDHILL. — Supt.,  C.Caldecott,  M.B. — Sec.,  Henry 
Howard,  15/16  Ludgate  Hill,  E.C.  (600) 


WARWICK. 

m.f.  MIDLAND  COUNTIES  INSTITUTION,  KNOWLE,  NEAR  BIR- 
MINGHAM.— Sec.  and  Supt.,  H.  Williams.  (129) 

/.  AGATHA  STACEY  HOME,  REDNAL,  NEAR  BIRMINGHAM 
(Birmingham  County  Borough). — Financial  Sec.,  Miss  C.  P. 
Fleetwood,  158,  Broad  Street,  Birmingham;  Supt.,  Miss 
Smith.  (35) 

/.  AGATHA  STACEY  HOME,  ENNISKERRY,  KNOWLE. — Financial 
Sec.,  Miss  C.  P.  Fleetwood,  158,  Broad  Street,  Birmingham; 
Supt.,  Miss  Davis.  (24) 


APPENDIX  A  249 


Institutions  Approved  under  Section  37. 
(Poor  Law  Cases.) 

CHESHIRE. 

m.f.  CHESTER  WORKHOUSE  IMBECILE  WARDS,  HOOLE. — 
Supts.,  Medical  Officer  and  Master  of  Workhouse.  (25) 

ESSEX. 

m.f.  TENDRING  UNION  WORKHOUSE,  TENDRING,  HARWICH. — 
S'ltpt.,  Henry  James  Burden.  (46) 

HAMPSHIRE. 

m.  PARISH  INFIRMARY  BUILDINGS,  SHIRLEY  WARREN, 
SOUTHAMPTON  (Southampton  County  Borough) — Supt., 
J.  C.  Young,  M.R.C.S.,  L.R.C.P.  (54) 


KENT. 

m.f.  CROYDON  UNION  WORKHOUSE. — Supt.,  Dr.  R.  W. 
Wilson.  (6) 

LANCASHIRE. 

m.f.  SEAFIELD  HOUSE,  SEAFORTH,  LIVERPOOL. — Supt.,  S.  J. 
Towill.  (269) 

NORTHUMBERLAND. 

m.f.  PRUDHOE  HALL  COLONY,  and  BURN  HOUSE,  PRUDHOE 
(Newcastle  County  Borough). — Matron,  Miss  N.  M.  Hawkes. 

(105) 

STAFFORD. 

m.f.  GUARDIANS  INSTITUTION,  LONDON  ROAD,  STOKE-ON- 
TRENT  (Stoke-on-Trent  County  Borough). — Supt.,  C. 
Gray  son.  (20) 


2  50      MENTALLY  DEFICIENT  CHILDREN 

m.f.  MENTAL  WARDS,  UNION  WORKHOUSE,  HEATH  TOWN, 
WOLVERHAMPTON  (Wolverhampton  County  Borough). — 
Supt.,  T.  D.  Rollinson.  (31) 

m.f-  WALSALL  UNION  POOR  LAW  INSTITUTION,  PLECK  ROAD, 
WALSALL  (Walsall  County  Borough). — Supts.,  W.  J. 
Humphries  and  Mrs.  Humphries.  (12) 

m.f.  BURTON-ON-TRENT  UNION  WORKHOUSE. — Sttpt.,  Robert 
Barcham.  (20) 

WILTS. 
/.  PEWSEY  UNION  WORKHOUSE. — Supt.,  H.  England.         (4) 

/.  UNION  WORKHOUSE,  ST.  JAMES,  DEVIZES.  —  Supt.,  W. 
Fear.  (16) 

m.f.  CHIPPENHAM  UNION  WORKHOUSE. — Supt.,  Jas.  B. 
Pierce.  (21) 

/.  TROWBRIDGE  UNION  WORKHOUSE. — Supt.,  Chas.  H. 
Taylor.  (24) 

WORCESTERSHIRE. 

m.f.  EVESHAM  UNION  WORKHOUSE  INFIRMARY. — Supt.,  J.  H. 
Damen.  (8) 

m.f.  MONYHULL  COLONY,  KING'S  HEATH,  BIRMINGHAM  (Bir- 
mingham County  Borough). — Supt.,  Miss  Carse.  (i°o) 


YORKSHIRE. 

m.f.  POOR-LAW  INSTITUTION,  75,  HARTINGTON  ROAD,  YORK. 
—Sup'.,  w.  E.  Jenner.  (30) 


APPENDIX  A  251 


Certified  Houses.    (Proprietary  Homes  for 
Private  Cases,  etc.) 

*  Houses  thus  marked  for  private  cases  only. 

DERBYSHIRE. 

*m.f.  RYDAL  HOUSE,  TENNYSON  AVENUE,  CHESTERFIELD. — 
Supt.,  Miss  Augusta  Mole.  (6) 

LANCASHIRE. 

/.  LIN  WOOD  AND  YORK  VILLA,  CROMPTON  ROAD,  FORMBY, 
NEAR  LIVERPOOL. — Supt.,  Miss  Ethel  Hobday.  (44) 

m.  LINTHAL,  BARKFIELD  AVENUE,  FORMBY,  NEAR  LIVERPOOL. 
— Supt.,  Miss  K.  Bowyer.  (32) 

MIDDLESEX. 

*m.f.  FERNHURST,    8,  MATTOCK   LANE,    EALING,  W. — Supt., 
Miss  S.  M.  Macdowall.  (19) 

*Wl.f.  NORMANSFIELD,  HAMPTON  WlCK,  KlNGSTON-ON-THAMES. 

— Supts.,  R.  L.  Langdon-Down,  M.B.,  and  P.  L.  Langdon- 
Down,  M.B.  (14°) 

*m.f.  THE    GABLES,  UPPER    TEDDINGTON   ROAD,  HAMPTON 
WICK,  KINGSTON-ON-THAMES. — Supt.,  Miss  F.  H.  Deck. 

(18) 

*m.f.  ARNISTON,  THE  GROVE,  ISLEWORTH. — Supts.,  Miss  J.  M. 
and  Miss  M.  D.  Isbister.  (12) 

SOMERSET. 

*/.  DOWNSIDE  LODGE,  CHILCOMPTON,  BATH. — Supt.9  Miss  C.  E. 
Short.  (7) 

SUSSEX. 

m.f.  12,  UPPER  MAZE  HILL,  ST.  LEONARDS-ON-SEA. — Supt., 
Mrs.  J.  Meiklejon.  (38) 

YORKSHIRE. 

*/.  THE  GRANGE,  ALTOFTS,  NORMANTON. — Supt.,  Mrs.  E.  A. 
Howard.  (15) 


2  52      MENTALLY  DEFiCiEtfT  CHILDREN 


Approved  Homes.    (Training  Schools  for 
Uncertified  Improvable  Cases.) 

*  Homes  thus  marked  are  proprietary  Training  Schools  for  private  patients. 

CORNWALL. 

/.  ELIZABETH  BARCLAY  HOME  OF  INDUSTRY,  BODMIN. — Hon. 
Sec.,  Miss  E.  M.  S.  Shaw;  Supt.,  Miss  Emily  Hunt.  (26) 

DERBY. 

/.  MAGDALENE  HOUSE,  CROMWELL  ROAD,  CHESTERFIELD 
(Managed  by  Committee). — Supt.,  Miss  Root.  (6) 

DORSET. 

/.  KING'S  GATE,  AND  FRITKSTOW,  WEST  MOORS. — Manager, 
Miss  B.  James,  10,  Bolton  Court,  London,  S.W. ;  Supt.,  Miss 
A.  H.  Egan.  (12) 

ESSEX. 

m.  GAY  BOWERS,  WEST  HANNINGFIELD,  CHELMSFORD. — 
Supts.,  P.  Chennells  and  Mrs.  G.  Chennells.  (7) 

GLOUCESTERSHIRE. 

/.  MARY  CARPENTER  HOME,  598  AND  600,  FISHPONDS  ROAD, 
BRISTOL,  and  BRANCH  HOME  AT  WESTRA,  YATE  (Bristol 
County  Borough  and  Gloucester  County  Council). — Hon. 
Sec.,  Mrs.  Gilmore  Barnett;  Supt.,  Miss  Edwards;  18  female 
defectives  at  Fishponds  Home  and  7  at  Branch  Home, 
Westra,  Yate.  (25) 

/.  ROYAL  FORT  HOME,  BRISTOL  (Bristol  Preventive  Mission). 
— Supt.,  Miss  Blanche  Whiteaway.  (15) 

*m.f.  SOUTHEND  HOUSE  SCHOOL,  PITVILLE,  CHELTENHAM. — 
Supt.,  Miss  A.  King-Turner.  (16) 

KENT. 

m.  UPPER  HOLLANDEN  FARM,  PRINCESS  CHRISTIAN  FARM 
COLONY,  HILDENBORO'  (Application  to  Miss  Kirby,  Sec., 
N.A.F.M.,  Denison  House,  Vauxhall  Bridge  Road,  S.W.) — 
Supt.,  Miss  E.  J.  Price.  (See  also  Certified  Institutions.)  (8) 

LEICF;STER. 

/.  SUNNYHOLME,  155,  KING  RICHARD'S  ROAD  (Leicester 
County  Borough,  managed  by  After-Care  Committee). — 
Hon.  Sec.,  Miss  A.  E.  Clephan,  no,  Regents  Road, 
Leicester. — Supt.,  Miss  Gertrude  Annie  Ladkin.  (12) 


APPENDIX  A  253 


MIDDLESEX. 

/.  ALEXANDER  HOUSE,  117,  HIGH  STREET,  UXBRIDGE 
(Application  to  Miss  Kirby,  Sec.,  N.A.F.M.,  Denison 
House,  Vauxhall  Bridge  Road,  S.W.)—Supt.,  Miss  Ellen 
Collyer.  (24) 

*m.f.  BROOK  HOUSE,  SOUTHGATE,  N. — Supt.,  Dr.  H.  Corner. 

(37) 

*m.f.  ST.  CHRISTOPHER'S  (SCHOOL),  AMHERST  ROAD,  EALING, 
W. — Supt.,  Miss  M.  C.  B.  Foster.  (22) 

*m.f.  CONIFERS,  KINGSTON  ROAD,  HAMPTON  WICK. — Supt., 
Miss  Florence  Eddolls.  (Drs.  Langdon-Down.)  (10) 

*m.  TREMATON,  BROOM  ROAD,  HAMPTON  WICK. — Supt.,  Miss 
A.  G.  Mackay.  (Drs.  Langdon-Down.)  (12) 

NORTHUMBERLAND. 

/.  HOME  OF  INDUSTRY,  Bow  VILLA,  MORPETH  (Managed  by 
Committee). — Supt.,  Miss  A.  A.  Pawsey.  (16) 

SOMERSET. 

/.  HOUSE  OF  HELP  FOR  WOMEN  AND  GIRLS,  112,  WALCOT 
STREET,  BATH  (Bath  County  Borough).  —  Sec.,  Miss 
Twiss;  Supt.,  Miss  Alice  Lilian  Walker.  (50) 

SUSSEX. 
(Mrs.  Meiklejon's  Homes.) 

*m.f.  BROOKLANDS,  23,  UPPER  MAZE  HILL,  ST.  LEONARDS- 
ON-SEA. — Supt.,  Miss  A.  Lavers.  (10) 

*/.    TlPPERARY,  22,  UPPER  MAZE  HlLL,  ST.  LEONARDS-ON-SEA. 

— Supt.,  Miss  A.  Lavers.  (35) 

SUFFOLK. 

/.  HANDFORD  HOME  FOR  FEEBLE-MINDED  GIRLS,  RANELAGH 
ROAD,  IPSWICH.— Hon.  Sec.,  Mrs.  Alan  Turner,  Crane  Hall, 
Ipswich;  Supt.,  Miss  Florence  Church.  (20) 

YORKSHIRE  (N.R.). 

*m.f.  THE  MOUNT,  WHITBY. — Supt.,  Mrs.  Annie  E.  Priestly. 

(12) 
FLINTSHIRE. 

m.f.  "  WALMER  "  SCHOOL  FOR  BLIND  AND  DEAF,  RHYL. 
—Supt.,  Mrs.  Elizabeth  Roberts.  (13) 


254      MENTALLY  DEFICIENT  CHILDREN 


(List  kindly  furnished  by  Clerk,  June,  1915.) 

METROPOLITAN  ASYLUMS  BOARD. 

INSTITUTIONS  FOR  IMBECILES  AND  FEEBLE-MINDED,  ETC. 

(From  London  Parishes.) 


A  ccommodation  . 

Males. 

Females. 

Total 

Asylums  for  unimprovable  imbeciles 

(certified)  : 

Leavesden 

1,007 

1,188 

2,195 

Caterham 

1,017 

1,092 

2,109 

Tooting  Bee: 

(i)  Asylum* 

486 

57<3 

1,062 

(2)  Receiving-home  for  children 

28 

24 

52 

Fountain  (temporary) 

363 

303 

666 

Industrial    Colonies    for   improvable 

imbeciles     (certified)     and     for 

feeble-minded  (uncertified)  : 

Daren  th  : 

Improvable  imbeciles 

884 

784 

1,668 

Feeble-minded    .. 

320 

310 

630 

Bridge  : 

Feeble-minded 

210 

— 

200 

4>3i5 

4>277 

8,592 

*  This  asylum  is  now  being  extended.  When  finished,  it 
will  contain  942  male,  1,226  female,  and  52  beds  for  chil- 
dren— Total,  2,220. 


APPENDIX  A 


255 


(List  kindly  supplied  by  General  Board  of  Control, 
Scotland,  1915.) 

SCOTLAND. 
CERTIFIED  INSTITUTIONS. 


Licensed  for  — 

Name  of  Institution. 

Pri- 
vate. 

Aided. 

Class  of  Defectives  to  be 
Accommodated. 

M.|  F. 

M. 

F. 

BALDOVAN,  near  Dundee. 

2 

60 

Imbecile  and  mentally 

Med.  Supt.,  Dr.  W.  B. 

defective  children 

Drummond 

GRIERSON    HALL,   Dum- 

50 

50 

Private  and  aided  de- 

fries 

fectives  over  1  6 

LARBERT,      Stirlingshire. 

350 

Imbecile  and  mentally 

Med.  Supt.,  Dr.  R.  D. 

defective  children 

Clarkson 

MIDDLETON    HALL,    Lin- 

65 

Males     of     Edinburgh 

lithgowshire 

parish 

OUARRIER'S     HOMES, 

68  m.  44  f. 

Epileptics  of  school  age, 

Bridge  of  Weir,    Ren- 

Protestants 

frewshire 

STONEYETTS,     Chryston, 

174 

T7I 

Adults  and  ineducable 

near  Glasgow 

juveniles  of  Glasgow 

parish 

WAVERLEY    PARK,    Kir- 

QO 

Educable      girls      be- 

kintilloch, nr.  Glasgow 

tween  5  and  16  years 

IRELAND. 
(Not  included  under  Mental  Deficiency  Acts.) 

STEWART  INSTITUTION  FOR  IDIOTIC  AND  IMBECILE  CHILDREN. 
Palmerston  House,  Chapelizod,  Co.  Dublin. — no  boys 
and  girls.  Med.  Supt.,  Dr.  Rainsford;  Sec.,W.  M'c.  O'Neill. 

BRITISH  DOMINIONS. 

Canada  :  Orillia,  ONTARIO  HOSPITAL  FOR  FEEBLE-MINDED 
(800).  Med.  Supt.,  Dr.  A.  M.  Beaton. 

Australia  :  KEW  ASYLUM  ANNEXE  FOR  IDIOTS,  near  Mel- 
bourne; ADELAIDE  INSTITUTION,  S.  Australia. 

New  Zealand  :  STATE  INSTITUTION  FOR  MENTALLY  DEFECTIVE 
BOYS,  Otckaike,  Oamaru. 

South  Africa :  DEPARTMENT  FOR  DEFECTIVE  CHILDREN: 
GRAHAMSTOWN  ASYLUM. 


256      MENTALLY  DEFICIENT  CHILDREN 


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APPENDIX  B 


259 


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260      MENTALLY  DEFICIENT  CHILDREN 


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APPENDIX  C 


261 


II.  SIMPLE  VOWEL  SOUNDS. 


Vowel  Sound. 

Examples. 

A  (open)        =(Ah) 

Father 

A  (broad)      =  (Aw) 

All  (Awtul) 

A  (short)       =A 

Cap,  Tap 

A  (long)         =A 

Cape,  Tape 

O  (short)       =6 

Cot,  Knot 

O  (long)         =0 

Coat,  Note 

56  (short)    =(66) 

Foot,  Wood 

OO  (long)      =  (OO) 

Boot,  Food 

U  (short)       -U 

Tun,  Fun 

U  (long)         =U 

Tune,  Fume 

E  (short)       =£ 

Bed,  Fed 

E  (long)         =E 

Bead,  Feed 

I  (short         =1 

Bit,  Fit 

I  (long)          =1 

Bite,  Fight 

Aspirate  H                                  Hat,  Hall 

Double  Letters  W,  Y               Wall,  You 

Diphthongs,  6t,  OW                Oil,  Owl 

[Arranged  by  Dr.  Shuttleworth  for  use  at  Royal  Albert 
Asylum.  Reprinted  from  his  article  on  "  Education  of 
Imbeciles  "  in  Dr.  Hack  Tuke's  "  Dictionary  of  Psychological 
Medicine,"  by  kind  permission  of  Messrs.  Churchill.] 


The  following  phonetic   phrases  (from  Dr.  Wyllie's  book) 
are  serviceable  for  speech  testing : — 

1.  (Labials)  "  Peter  Brown  made  white  wax." 

2.  (Labio-dentals)  "  Fine  villages." 

3.  (Linguo-dentals)  "  Thinkest  thou  so,  Zealot  ?" 

4.  (Anterior  linguo-palatals)  "  She  leisurely  took  down  nine 
large  roses." 

5.  (Posterior  linguo-palatals)  "  Can  Gilbert  bring  Loch  Hourn 
youths  ?" 


262         APPENDIX  D.— L.C.C.   "SPECIAL"    MENTAL! 

ELDER   BOy 
(Staff:  i  Head  Master,  4  Assistant  Maste 


1  6 

9-30 
to 

9.40  to 

10.0  to 

10.35 
to 

10.55 
to 

II.  IO 

to 

II.  2O  to 

11.40  to 

«—  i  ^ 

IO.O. 

10.35. 

11.40. 

12.  0. 

O 

9.40. 

10.55- 

II.  IO. 

11.20. 

•    i 

Scripture 

Arithmc. 

Readg. 

Recitation 

Writing 

K| 

2 

d 

Q 

3 
4 

" 

Hand 

work 

11 

f  1 

0 

1 

'; 

» 

O 

*a 

Woodwork 

Wood 

work 

o                 Wood 

work 

b 

Bootmaking 

Boot 

making 

PH  (3 

P^                   Boot 

making 

c 

Tailoring 

Tailor 

ing 

Tailor 

ing 

i 

Hymns 

Arithmc. 

Readg. 

Oral  Comp. 

Writing 

Q 

2 

3 

Scripture 

» 

» 

•§J 

3 

j> 

» 

C/) 

4 

Hand 

work 

11 

rt 

i 

a 

g 

Woodwork 

Wood 

work 

OJ 

"Wood 

work 

H 

b 

Mj 

Bootmaking 

Boot 

making 

^  w 

« 

Boot 

making 

c 

Tailoring 

Tailor 

ing 

Tailor 

ing 

^ 

, 

1 

Scripture 

Basket 

work 

Basket 

work 

Q 

C/3 

W 

2 

3 
4 

1 

» 

Arithmc. 

Readg. 

|| 

cS 

.2 

Recitation 

Geograpb 

Z 

a 

(/) 

Woodwork 

Wood 

work 

A    K 

0 

"Wood 

work 

§      b 

•| 

Bootmaking 

Boot 

making 

Pn  pq 

Pn 

Boot 

making 

s 

c 

* 

Tailoring 

Tailor 

irig 

Tailor 

ing 

i 

1 

Scripture 

Arithmc. 

Readg. 

Wordbuildg 

Geograpl 

< 

2 

,, 

,, 

,, 

F—  (        & 

,, 

,, 

p 

3 

o> 

Hymns 

Hand 

work 

o  .§ 

'•£                    » 

Object  Le: 

f3 

4 

}) 

Arithmc. 

Readg. 

"0  " 

cJ      i 

,, 

£ 

a 

Woodwork 

Wood 

work 

g    8    :       §                         Wood 

work 

n 

b 

Bootmaking 

Boot 

making 

^       &                   Boot 

making 

H 

c 

;    Tailoring 

Tailor 

ing 

Tailor 

ing 

i 

Scripture 

Arithmc. 

Readg. 

Oral  Comp. 

Dictatio 

;* 

2 

„ 

»               _<     t/5 

^3  «? 

•d 
.2 

3 

o  .ty 

Q 

4 

Hand 

work 

*co    ft 

cd 

CL) 

tt 

,, 

5 

a 

Woodwork 

Wood 

work 

A    « 

o                 Wood  work 

& 

b 

iBootmaking 

Boot 

making 

PH  pq 

ft 

Bootmaking 

c 

Tailoring 

Tailor 

ing 

Tailoring 

*  Classes  a,  b,  c,  are  section:  ' 


•EFECTIVE   SCHOOL   TIME  fcTABLE,    1914-15. 

EPARTMENT. 

Manual  Instructors  ;  Accommodation  126.) 


•  30 
to 
•35- 

1.35  to  2.IO. 

2.10  to  2.35. 

2-35  to  3-5- 

3-5 
to 
3.20. 

3.20  to  3.55. 

3-55 
to 
4.0. 

| 

:  co 

'd 

03 

3 

Arithmetic 

Handwork 
Arithmetic 
Woodwork 
Bootmaking 
Tailoring 

Reading 

Handwork 
Reading 
Wood 
Boot 
Tailor 

Drawing  (pattern) 

Handwork 
Drawing  (colour) 
work 
making 
ing 

03 

1 

Singing 
Geography 

Woodwork 
Bootmaking 
Tailoring 

'rt 

C/) 

5 

03 

1 

£ 

Arithmetic 

Handwork 
Arithmetic 
Woodwork 
Bootmaking 
Tailoring 

Reading 

Handwork 
Reading 
Wood 
Boot 
Tailor 

Phys.  Ex.  &  Games 
Singing 

work 
making 
ing 

i 

History 

Woodwork 
Bootmaking 
Tailoring 

Arithmetic 
Basketwork 
Arithmetic 

„ 
Woodwork 
Bootmaking 
Tailoring 

Reading 
Basket 
Reading 

"  Wood 
Boot 
Tailor 

Drawing  (woodwk.) 
work 
Drawing  (colour) 
(pattern) 
work 
making 
mg 

)_i 

Singing 
Story-telling 

Woodwork 
Bootmaking 
Tailoring 

Arithmetic 

Handwork 
Woodwork 
Bootmaking 
Tailoring 

Reading 

Handwork 
Wood 
Boot 
Tailor 

Drawing  (colour) 

,,         (pattern) 
Handwork 
work 
making 
ing 

Recreation 

Story-telling 

>> 
Singing 

Woodwork 
Bootmaking 
Tailoring 

Arithmetic 

Woodwork 
Bootmaking 
Tailoring 

Reading 

"  Wood 
Boot 
Tailor 

Drawing 
,,         (memory) 
Phys.  Ex.  &  Games 

work 
making 
ing 

Recreation 

Object  Lesson 

Woodwork 
Bootmaking 
Tailoring 

264      MENTALLY  DEFICIENT  CHILDREN 


APPENDIX  E 

MENTAL  DEFICIENCY  ACT,   1913,  S.  3,  5,   ETC. 
[Form  P4-] 

MEDICAL  CERTIFICATE. 

In   the   matter   of   A.B.  ,    of 

in  the  County (*)  of  ,  an  alleged  defective. 

I,  the  undersigned,  K.L.  ,  do  hereby  certify 

as  follows : 

1.  I  am  a  person  registered  under  the  Medical  Acts  and  I 
am  in  the  actual  practice  of  the  medical  profession   [and 
approved  by  the  Local  Authority  for  the  County  (*)  of 

or  by  the  Board  of  Control,  for  the  purpose  of  giving  medical 
certificates  under  the  above  Act]  [and  the  usual  medical 
attendant  of  the  said  A.B.  ] 

2.  On  the  day  of  ,  (f)  at 

,  in  the  County  (*)  of 

separately  from  any  other  practitioner,  I  personally  examined 
the  said  A.B.  and  satisfied  myself 

that  he  was  .(J) 

3.  I  formed  this  conclusion  on  the  following  grounds,  viz. : 

(a)  Facts  observed  by  myself — 

(i.)  at  the  time  of  examination ; 
(ii.)  previously  to  examination.  (§) 

(b)  Facts  communicated  by  others. 

4.  The  said  A.B.  appeared  to  me  to  be 
[or  not  to  be]  in  a  fit  condition  of  bodily  health  to  be  removed. 

Dated 

Signed 


*  Or  County  Borough. 

t  The  examination  must  have  taken  place  not  more  than 
seven  clear  days  before  the  date  of  the  presentation  of  the 
petition  or  admission  of  patient. 

{  State  whether  an  idiot,  an  imbecile,  a  feeble-minded 
person,  or  a  moral  imbecile.  If  the  defective  be  certified 
otherwise  than  as  an  idiot  or  imbecile,  the  sanction  of  a  judicial 
Authority  is  also  required  (S.  3). 

§  Give  date  when  observed. 

||  Insert  postal  address. 


BIBLIOGRAPHY 

1.  De  1' education  d'un  Homme  Sauvage,  Itard.     Paris,  1801. 

2.  Observations  pour  servir  a  1'histoire  de  1' Idiotic,  Esquirol 

(Maladies  Mentales) .     Paris,  1828. 

3.  Die  Heilung  und  verhiitung  des  Cretinismus,  etc.,  Gug- 

genbuhl.     Bern,  1835. 

4.  Resume  de  ce  que  nous  avons  fait  pendant  quatorze  mois, 

Esquirol  et  SSguin.     Paris,  1839. 

5.  Traitement  Moral,  Hygiene  et  Education  des  Idiots,  etc., 

E.  S6guin.     Paris,  1846.* 

6.  Articles  on  Idiocy  in  Chambers'  Edinburgh  Journal,  by 

Mr.  Gaskell.     January  and  February,  1847. 

7.  Remarks  on  the  Education  of  Idiots  and  Children  of  Weak 

Intellect,  W.  R.  Scott,  Ph.D.     London,  1847. 

8.  Article  by  Dr.  Conolly  in  British  and  Foreign  Medico- 

Chirurgical  Review.     London,  1847. 

9.  Causes  and  Prevention  of  Idiocy  (Report  to  Mass.  Legisla- 

ture), Dr.  S.  G.  Howe.     Boston,  Mass.,  1848. 

10.  Report  of  Commission  created  by  King  of  Sardinia  for 

Study  of  Cretinism.     Turin,  1850. 

11.  Researches  on  Idiocy  and  Cretinism  in  Norway,  Dr.  Stalst. 

Christiania,  1851. 

12.  On  the  Possibility  of  Educating  Idiot  Children,  Dr.  Ehr- 

chricht.     Copenhagen,  1854. 

13.  Cretinism  and  Idiocy,  Dr.  Blackie.     Edinburgh,  1855. 

14.  Idiot  Training,  Rev.  Edwin  Sidney.     London,  1855. 

15.  Idiots  and  the  Efforts  for  their  Improvement,  Dr.  L.  P. 

Brockett.     Hartford,  Conn.,  1856. 

1 6.  Report  of  Commissioners  on  Idiocy  in  Connecticut  (Knight 

and  Brockett).     Dorchester,  Conn.,  1856. 

*  Reprinted  by  Dr.  Bourneville  in  Publications  du  Progrls 
Medical.  Bibliotheque  d' Education  Speciale,  III.  bis.  Paris, 
1906. 

265 


266      MENTALLY  DEFICIENT  CHILDREN 

17.  Handbook  of  Idiocy,  James  Abbott.     London,  1857.     \. 

1 8.  The  Mind  Unveiled,  Dr.  Isaac  N.  Kerlin.     Philadelphia/^ 

1858. 

19.  Suggestions  on  Principles  and  Methods  of  Elementary  In- 

struction, Dr.  W.  B.  Wilbur.     Albany,  New  York,  1862. 

20.  The  Idiot  and  his  Helpers,  W.  Millard.     Colchester,  1864. 

21.  Idiocy  :  its  Diagnosis  and  Treatment  by  the  Physiological 

Method,  E.  SSguin,  M.D.     Albany,  1864. 

22.  Manual  for  the  Classification,  Training,  etc.,  of  the  Feeble- 

minded, Imbecile,  and  Idiotic,  Duncan  and  Millard. 
London,  1866. 

23.  Idiocy  and  its  Treatment  by  the  Physiological  Method, 

E.  S6guin,  M.D.     New  York,  1866.* 

24.  New  Facts  and  Remarks  concerning  Idiocy,  E.  S6guin, 

M.D.    -New  York,  1870. 

25.  Two  Cases  of  Microcephalic  Idiocy,  G.  E.  Shuttleworth, 

M.D.    British  Medical  Journal,  August,  1875. 
\  26.  Education  and  Training  of  the  Feeble  in  Mind,  J.  Langdon- 
Down,  M.I).     London,  1876. 

27.  Notes  of  Visit  to  American  Institutions  for  Idiots  and 

Imbeciles,  G.  E.  Shuttleworth,  M.D.     Lancaster,  1877. 

28.  Case  of    Microcephalic  Imbecility,    G.   E.   Shuttleworth, 

M.D.     Journal  Mental  Science,  October,  1878. 
x>*9.  Some  ofj;he  Cranial  Characteristics  of  Idiocy.    Id.    Trans. 

International  Medical  Congress,  1881. 
30.  The  Idiot :  his  place  in  Creation,  Sir  Frederick  Bateman, 

M.D.     London, 1882. 
^  31.  Types  of  Imbecility,  Fletcher  Beach,  M.B.   Medical  Times 

and  Gazette.     London,  1882. 

^32.  The  Physical  Features  of  Idiocy,  G.  E.  Shuttleworth,  M.D. 
Liverpool  Med.-Chir.  Journal,  July,  1883. 

33.  Is  Legal  Responsibility  acquired  by  Educated  Imbeciles  ? 

Id.     Journal  Mental  Science,  January,  1884. 

34.  The  Health  and  Development  of  Idiots  as  compared  with 

Mentally  Sound   Children.     Id.     International   Health 
Exhibition  Literature,  vol.  xi.t  p.  526.     London,  1884. 

*  Reprinted  by  Teachers'  College,   Columbia  University, 
New  York,  1907. 


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268      MENTALLY  DEFICIENT  CHILDREN 

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64.  Diagnosis  and  Prognosis  of  Certain  Forms  of  Imbecility, 

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66.  Clifford  Allbutt's  System  of  Medicine,  vol.  viii.     Article 

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BIBLIOGRAPHY  269 

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73.  On  the  Relations  of  Epilepsy  to  Amentia,  A.  F.  Tredgold, 

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74.  The  Problem  of  the  Morally  Defective,  W.  A.  Potts,  M.D. 

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^5.  Mental  Defectives  :  their  History,  Treatment,  and  Train- 
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77.  Traitement  Medico -Pedagogique  de  1'Idiotie,  Dr.  Bourne- 

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78.  Functional  Nervous  Disorders  in  Childhood,  Leonard  G. 

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Some  Types  of  Congenital  Mental  Defect  and  their 
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83.  The  Problem  of  the  Feeble-minded,  Mary  Dendy.     Man- 

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84.  Inherited  Syphilis  as  a  Factor  in  the  Etiology  of  Mental 

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y 


270      MENTALLY  DEFICIENT  CHILDREN 

85.  The  Relation  of  Alcoholism  to  Feeble-mind edness,  W.  A. 
Potts,  M.D.    British  Journal  of  Inebriety,  London,  1908. 
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87.  The  Aphasias  of  Childhood  and  Educational  Hygiene, 

C.  J.  Thomas,  M.B.     London,  1908. 

88.  Guide  to   the  Clinical  Examination  and  Treatment  of 

Sick  Children,  John  Thomson,  M.D.     Edinburgh  and 
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89.  fitud'e    Anatomique    de    1'Idiotie    Mongolienne,    M.    L. 

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90.  Common  Disorders  and  Diseases  of   Childhood,    G.   F. 

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91.  Physiological  Variations  in  Children,  James  Kerr,  M.A., 

M.D.     Medical  Chronicle,  July,  1909. 

92.  Mongolian  Imbecility,  G.  E.  Shuttle  worth,  M.D.    British 

Medical  Journal,  September  n,  1909. 

93.  Mendel's  Principles  of  Heredity,  W.  Bateson.     Cambridge 

University  Press,  1909. 

94.  Feeble-mind  edness  and  Juvenile  Crime,  G.  A.  Auden,  M.D. 

Birmingham  Medical  Review,  1910. 

95.  Care  and  Training  of  the  Feeble-minded,  A.  R.  Douglas, 

L.R.C.P.  and  S.     Journal  of  Mental  Science,  1910. 

96.  Allbutt   and    Rolleston's  System   of    Medicine,  vol.  viii. 

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97.  Care  and  Control  of  the  Feeble-minded,  Ellen  F.  Pinsent. 

Nineteenth  Century  and  After,  July,  1910. 

98.  Mental  and  Physical  Tests,   G.  M.  Whipple.     Warwick 

and  Yorke,  Baltimore,  1910. 

99-  Oxycephaly,  W.  A.  Potts,  M.A.,  M.D.     The  Child,  Novem- 
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100.  Prevention    of    Feeble-mindedness,    E.    R.    Johnstone. 

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London,  1911. 

102.  Our   Provision  for   the   Mentally   Defective,    Ellen   F. 

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103.  Training  of  the  Mentally  Defective  in  Special  Schools, 

W.  A.  Potts,  M.A.,  M.D.  Papers  and  Proceedings  of 
the  National  Conference  on  the  Prevention  of  Destitution. 
London,  1911. 

104.  The  Deaf  Child,  James  Kerr  Love,  M.D.   Wright,  Bristol, 

1911. 

105.  Feeble-mindedness  in  Children  of  School  Age,  C.  Paget 

Lapage,  M.D.     University  Press,  Manchester,  1911. 

106.  Measurement  of  Mental  Ability  of  Backward  Children, 

A.  R.  Abelson,  D-fcs-L.  British  Journal  of  Psychology, 
1911. 

107.  The  Binet-Simon  Measuring  Scale  for  Intelligence,  H.  H. 

Goddard,  Ph.D.  The  Training  School,  1911.  Vineland 
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108.  Tests  of  Intelligence,  W.  A.  Potts.  M.A.,  M.D.    British 

Medical  Journal,  April,  1912. 

109.  The  Kallikak  Family,  a  Study  in  the  Heredity  of  Feeble- 

mindedness, H.  H.  Goddard,  Ph.D.  Macmillan Co.,  New 

York,  1912. 
no.  The  Conservation  of  the  Child,  Arthur  Holmes,  Ph.D, 

J.  B.  Lippincott  Co.,  Philadelphia,  1912. 
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Wallin,  Ph.D.     Warwick  and  Yorke,  Baltimore,  1912. 

112.  Some  of  the  Methods  employed  in  the  Care  and  Training 

of  Feeble-minded  Children  of  the  Lower  Grades, 
W.  E.  Fernald,  M.D.  G.  H.  Ellis  Co.,  Boston,  1912. 

113.  What  is  a  Feeble-minded  Child?  Helen  MacMurchy,  M.D. 

Annual  Report,  Ontario  Women's  Institutes,  Toronto, 
1913- 

114.  The  Brain  in  Health  and  Disease,  Joseph  Shaw  Bolton, 

M.D.,  D.Sc.     E.Arnold,  1914. 

115.  Feeble-mindedness,  its  Causes  and  Consequences,  H.  H. 

Goddard,  Ph.D.     Macmillan  and  Co.,  1914. 

116.  Mental  Deficiency,  A.  F.  Tredgold,  L.R.C.P.,  M.R.C.S. 

2nd  edition,  Bailliere,  London,  1914. 

117.  Mental  Health  of  the  School  Child,  J.  E.  Wallace  Wallin, 

Ph.D.     Yale  University  Press,  1914. 

1 1 8.  Mentally  Defective  Children,  Alfred  Binet  and  Th.  Simon, 

M.D.  Translation  by  W.  B.  Drummond,  M.B. 
E.  Arnold,  London,  1914. 


272      MENTALLY  DEFICIENT  CHILDREN 

ng.  Industries  for  the  Feeble-minded,  A.  Bickmore.     Adlard 

and  Son,  London,  1914. 
1  20.  Seguin   and    his    Physiological   Method    of    Education, 

Henry  Holman,  M.A.    Sir  Isaac  Pitman  and  Sons,  Ltd. 

London,  1914. 

121.  What  Tests  in  Childhood  are  best  calculated  to  throw 

Light  upon  the  Capacities  of  Mental  Defectives  for 
Future  Work,  W.  A.  Potts,  M.D.     Lancet,  July,  1915. 

122.  Dementia  Praecox  and  Some  Neuroses  of  Adolescence, 

G.  E.  Shuttle  worth,  M.D.     School  Hygiene,  November, 


123.  Organization    and    Management    of    Auxiliary    Classes, 

Helen  MacMurchy,  M.D.     L.  K.  Cameron,  Toronto, 
1915- 

124.  Nature  and  Nurture  in  Mental  Development,  F.  W.  Mott, 

M.D.     John  Murray,  London,  1915. 

125.  Criminal  Imbecility,   H.  H.  Goddard,  Ph.D.     Vineland 

Training  School,  N.J.,  U.S.A.,  1915. 

126.  Kelynack's   Defective  Children   (article  on  Idiots  and 

Imbeciles,  by  Dr.  D.    Hunter).     London,  1915. 

REPORTS  AND  SERIALS. 

1.  Report  of  a  Special  Committee  of  the  Charity  Organiza- 

tion Society  on  the  Education  and  Care  of  Idiots,  etc. 
London,  1877. 

2.  Report  of  the  Royal  Commission  on  the  Blind,  the  Deaf, 

etc.     London,  1889. 

3.  Report  of  the  Departmental  Committee  on  Defective  and 

Epileptic  Children.     London,  1898. 

4.  Report  of  Royal  Commission  on  the  Care  and  Control" 

of  the  Feeble-minded  (8  vols.).     London,  1908. 

5.  Reports  of  Conferences  of  the  National  Association  for 

Promoting  the  Welfare  of  the  Feeble-minded. 

6.  Reports  of  Conferences  of  After-Care  Committees,  Bir- 

mingham, Leicester,  and  Nottingham,  1903-1905.  Sub- 
sequently After-Care  Conferences  of  the  National 
Association  for  Promoting  the  Welfare  of  the  Feeble- 
minded. 


BIBLIOGRAPHY  273 

7.  Reports  on  the  Feeble-minded  in  Ontario,  Toronto,  1906- 

1914.     Cameron,  Toronto. 

8.  Report  of  the  Commission  to  Investigate  the  Question  of 

the  Increase  of  Criminals,  Mental  Defectives,  Epileptics 
and  Degenerates  in  Massachusetts,  1911. 

9.  Annual  Reports  of  the  Chief  Medical  Officer  of  the  Board 

of  Education,  1910-1915.     Eyie  and  Spottiswoode. 

10.  Publications  of  the  Gal  ton  and  Biometric  Laboratories, 

University  of  London.     Cambridge  University  Press. 

11.  Journal  of  Mental  Science.  Churchill,  London,  1858-1915. 

12.  The  Psychological  Clinic,  Philadelphia,  U.S.A.,  1900-1915. 

13.  Journal  of  Psycho-Asthenics,  Faribault,  Minn.,  U.S.A., 

1900-1915. 

14.  The  Training  School  Bulletin.     Vineland,  N.  J.,  U.S.A., 

1904-1915. 

15.  The  Special    Schools    Quarterly,    Morris    and  Yeaman. 

Manchester,  1910-1915. 

16.  L'Enfance  Anormale.     Paris,  A.  Maloine,  1911-1915. 

17.  Nyt  Tidskrift  for  Abnormvaesenet  i  Norden.   Copenhagen, 

1899-1915. 

1 8.  The   British    Journal   of   Children's   Diseases.     London, 

1901-1915. 

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Mentally  Defective.     London,  1915. 

(And  Reports  of  British,  Irish,  American,  and  Continental 
Institutions  for  Defectives.) 


Publications  re  Mental  Deficiency  Act. 

1.  The  Mental  Deficiency  Act,  1913,  R.  A.  Leach.     London, 

L.G.B.  Press,  27,  Furnival  Street,  E.G.     2s.  6d. 

2.  A  Guide  to  the  Mental  Deficiency  Act,   1913,  J.  and  S. 

Wormald.     London,  P.  S.  King.     53. 

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Second  Edition,  1914.     London,  Stevens  and  Son.     los. 

18 


INDEX  OF  SUBJECTS 

ABNORMALITIES  of  cranium,  59,  105-8,  116-19 

of  nervous  action,  12,  16,  109-10,  160 
Abortion,  etc.,  attempts  at,  100 
Accidental  or  acquired  defect,  73,  8 1 
Accidents  (maternal)  during  gestation,  99 
Achondroplasia,  135 

Acts  of  Parliament.     Elementary  Education  (Defective  and 

Epileptic  Children)  Act  (1899),  n,  18,  19,   21, 

22,  41,  153,  162,  239;  (1903),  19;  (1914).  I0>  23> 

35,  42 

Mental  Deficiency  Act  (1913),   n,   27-33,   151,  153, 

161-2. 
Mental  Deficiency  and  Lunacy  (Scotland)  Act  (1913)* 

27,  33-4 
Adenoids,  184 

Adenoma  sebaceum,  65,  183 
Adolescence,  psychopathies  of,  142-52 
After-care,  need  for,  228-9,  235 

committees,  21-2,  235 
Alcoholism,  75,  96-9,  130,  163-4 
Amaurotic  family  idiocy,  75-6,  82,  130-1 
Amentia,  primary,  52,  64,  104,  uo-n 

secondary,  52,  104,  in,  114 
American  Institutions,  4-7,  38-9,  Appendix  B,  256-9 

results,  232-4. 

Approved  Homes,  32,  Appendix  A,  252-3 
.Articulation  (speech),  197-202,  Appendix  C,  260-1 
Asphyxia  neonatorum,  101,  no 
Asymmetry  of  cranium,  107-8 
Athetosis,  127,  189 
Attention,  defects  of  (aprosexia),  170,  189 

Backward  (or  intermediate)  classes,  165-7,  240 
Backwardness,  135,  165 
Bean-bags  (school  appliance),  188 
Belgium,  provision  in,  38 
Bibliography,  265-73 
Bicetre  Hospital,  Paris,  I 

274 


INDEX  OF  SUBJECTS  275 

Binet  and  Simon  tests,  116,  157-60,  163-5 

Birmingham   After-care   (Special  Schools)    Committee,    112, 

116,  228-9 
Birth,  causes  acting  at,  101-2;  previous  to,  99,  100 

Premature,  102 

Injury  at,  101 

Palsies,  72,  127 

Causes  acting  after,  102-4 
Board  of  Control,  26,  30 

Provisional  regulations,  32 

General,  for  Scotland,  34 

District,  in  Scotland,  34 
Board  of  Education : 

Departmental  Committee,  18-21 

"  Model  arrangements  "  (Special  Schools),  153-69 

Chief  Medical  Officer's  Annual  Reports,  41,  156,  163, 

167,  212-14 

Brains  of  defectives,  54-63 
Breathing  exercises,  198-9 
British  Dominions,  Institutions  in,  255 

Calculation,  cultivation  of,  205-6 

Causes  of  mental  deficiency.     See  Etiology 

Central  Association  for  Mentally  Defective,  235 

Cerebellum,  defect  of,  55 

Certificates  under  Mental  Deficiency  Act,  112-14 

Form  of  medical  certificate,  264 

Under  Elementary  Education  (Defective  and  Epi- 
leptic Children)  Act,  19,  154,  161-2 
Certified  Houses,  32,  251 
Certified  Institutions  (England  and  Wales),  31,  244-8 

(Scotland),  255 

Classification,  pathological,  ^z&z — 
Cleanly  habits,  promotion  of,  172-3 
Clothing,  173-4 

Colour  perception,  exercises  in,  195-6 
Committee  on  Children  (Dr.  Warner's),  11-13 
Conclusions  (and  results),  226-43 
Congenital  (simple)  types,  63-4 
Consanguinity  of  parents  (cousin  marriages),  88-9 
.  Consumption  and  mental  defect,  96 
Convulsions  during  dentition,  66,  102,  123 
Co-ordination,  exercises  to  promote,  187  seq. 
Corpus  callosum,  defects  of,  54 
Cranial  abnormalities,  105-9,  116-19 
Craniectomy,  184 
Cretinism,  77-8 

Sporadic,  78-9,  131-2, 
•  Table  of  differences  from  mongolism,  133-4 


276      MENTALLY  DEFICIENT  CHILDREN 


Criminality  and  mental  defect,  26,  138-40,  219-21 

Curricula  (specimen)  for  Mentally  Defective  Schools,  213-14, 

262-3 
Custodial  treatment,  211,  219,  224,  230 

Dancing  as  recreation,  211-12 
Defective  and  epileptic  children,  34 

Acts,  21-3 

Estimated  number,  19-20 
Defects  of  special  areas  of  brain,  64 
Definitions : 

Idiots,  27 

Imbeciles,  27 

Feeble-minded,  28,  35 

Moral  imbeciles,  28,  218-9 
Degeneration,  stigmata  of,  63-4 
Degenerative  changes  in  eyes,  76,  77,  121 

in  epilepsy,  148 
Dementia  praecox,  146-8 
Denmark,  provision  in,  37-8 

Departmental  Report  (defective  and  epileptic  children),  18-21 
Development  of  function  in  normal  infancy,  in 
Developmental  cases,  64-72,  81,  102 

defects,  12,  108-9 
Diagnosis,  104-41 
Diarrhoea,  treatment  of,  177 
Drawing,  instruction  in,  205 
Dressing  lessons,  203-4 
Dribbling,  repression  of,  173 
Drill,  202-3 
Dull  children,  165.     See  also  Backward 

Earnings  of  defectives,  227-8,  231-2,  241 

Echolalia,  200 

Eclampsic  cases,  66,  81,  102,  123 

Educational  training,  186-206 

Elder  boys  and  girls,  special  schools  (L.C.C.),  40 

Time  tables,  214,  262-3 

England  and  Wales,  provision  in,  3-4,  8-10,  244-54 
Enuresis,  172-3 

Environment  and  mental  defect,  89-92 
Epilepsy : 

Associated  with  primary  amentia,  64 

As  cause  of  secondary  amentia,  67,  81 

Developmental,  mental  degeneration  in,  148-9 

Pathology,  69 

Psychical,  223 

Status  epilepticus,  68 

Treatment,  177-81,  185 


INDEX  OF  SUBJECTS  277 

Epiloia  (tuberous  sclerosis),  65-6,  81,  183 
Etiology  (causation),  83-105 

Attempts  at  abortion,  100 

Environment,  89-92,  103 

Epilepsy,  67,  81,  103,  148 

Febrile  illnesses,  103 

Formative  defects,  12,  54 

Heredity,  83-9 

Infantile  convulsions,  102 

Instrumental  delivery,  101 

Maternal  conditions,  99 

Parental  intemperance,  96-9 

Phthisical  family  history,  96 

Premature  birth,  102 

Prolonged  birth,  101 

Shock  (emotional),  74,  103 

Syphilis  (inherited),  93-5 

Traumatism,  73,  103 
Exanthemata,  prognosis  in,  183 
Exercise,  importance  of,  174-5 
Eye  defects,  12,  74-5,  77,  121 
Eye  training,  195-6 

Family,  artificial  restriction  of,  100 
Family  history,  83-9,  159,  163-4 

Pasmore's  Chart  for,  opposite  p.  163 
Febrile  diseases,  103 
Feeble-minded,  use  of  the  term,  1 1 

Definition  of,  28,  35 

Illustrative  cases,  46-50 
Finger  training,  189-94,  207-11 
Forceps  delivery,  101,  107 
Form  and  size  boards,  192-3 
Formative  and  developmental  defects,  108-9 
Forms  of  mental  defect  (pathological  classification),  51-82 
France,  special  instruction  in,  2,  38 
"  Freddy,"  case  of,  59-60 
Fresh  air  and  exercise,  174,  208 
Fright  (or  shock),  103 
Functions,  normal,  development  of,  uo-n 

Games,  211-12 

Gardening,  208,  210 

General  paralysis  (juvenile),  71-2,  142-6 

General  treatment,  171-6 

Germ  cells,  86-7,  89 

Germany,  provision  of  special  instruction  in,  2,  36 

Glandular  deficiency,  80 


278      MENTALLY  DEFICIENT  CHILDREN 

Guardianship,  155-6,  236 
Gums,  spongy,  183 

Habits,  improvement  of,  172-3 
Hair  in  mongols  and  cretins,  134 
Hands  in  mongols,  120,  134 

Cretins,  131,  134 
Hearing,  196-7 

Heart,  anomalies  of,  in  mongols,  121 
Hebephrenia,  147 
Hemiplegia.     See  Paralysis 
Heredity  in  mental  defect,  83-89 

Chart  for  recording,  163 
"  Hilfsklasse  "  and  "  Hilf  schiilen, "  36-7 
Histological  changes  in  mental  defect,  52-3 
Homes,  "  Approved,"  32 

List  of,  252-3 

Educational,  for  better  class  children,  43 

Residential,  list  of,  244-51.     See  also  Certified  Homes 

and  Institutions 

Hydrocephalus,  60-1,  64,  106,  118 
Hypertrophy  of  brain,  61,  64,  106-7,  118 
Hysterical  affections  in  youth,  151 

Idiocy,  Seguin's  definition,  3 
Idiots,  statutory  definition,  27 
Idioglossia,  200-1 
Imbeciles,  statutory  definition,  27-8 

Moral,  statutory  definition,  28 

Moral,  218-25 

Inco-ordination  (muscular),  188 
Industrial  training,  207-15 
Inflammatory  (post-febrile)  cases,   129-30 
Inheritance.     See  Heredity,  83-9 
Inherited  syphilis,  70-2,  81,  93-5,  125 
Insanity  in  children,  151,  223 
Institutions,  Colonies,  Homes,  Schools,  etc. : 

England  and  Wales,  244-54 

Scotland,  255 

Ireland,  255 

British  (oversea)  Dominions,  255 

United  States  of  America,  4-7,  256-9 

Special  Schools,  39,  40-1 

Continental  Institutions,  36-9 
Intelligence,  tests  of,  111-14 

Binet  and  Simon's,  157-60 
Intemperance,  parental,  96-9 
Intermediate  schools  and  classes,  165-7,  24° 


INDEX  OF  SUBJECTS  279 

Ireland,  provision  in,  10,  255 
Italy,  provision  in,  38 

Juvenile  general  paralysis,  71,  142-6 
Joints,  laxity  of,  in  mongols,  120 

Kallikak  family,  89 

Kalmuc.     See  Mongol,  61-2,  119-122 

Katatonia,  147 

Kindergarten  methods,  187,  207 

Kleptomania,  150 

Lip  exercises,  173,  197-8 

Limbs,  contractions  of,  183-4 

Local  authorities  (England  and  Wales),  30-1,  33,  42,  153-167 

(Scotland),  34 
Lunacy  Commission  and  Board  of  Control,  30 

Macrame  work,  209 

Manual  training,  207-15,  241 

Marriage,  question  of,  237 

Masturbation,  175 

Maternal  conditions  during  gestation,  99-100 

Medical  examination  (Special  Schools),  154-169 

treatment,  176-83 
Melancholia,  152 

Mertdelism  (applied  to  mental  defect),  86-9 
Meningitis,  73-4 

Mental  Deficiency  Acts.     See  Acts  of  Parliament 
Mental  retardation  (Binet  and  Simon's  tests),  157,  165 
Microcephalus,  59-60,  105-6,  116-7 
Microkinesis,  109 
Mind-blindness,  58 
Mixed  types,  135 

^  Model  arrangements,"  Board  of  Education,  153  seq.,  168-9 
"  Mongol  "  cases,  61-27^4,  107,  119-22,  177 

Diagnosis  from  cretinism,  133-4 
Montessori  method,  191-4 

Moral  defects,  136-41,  149-51.     See  also  Moral  training,  216-25 
Moral  defectives  and  imbeciles,  58,  139-41,  149-51,  218-25 
Moron,  the  term,  u 
Mortality  from  tubercle,  176-7 
Muscular  activity,  promotion  of,  172 
Music,  value  of,  in  training,  196-7,  202,  212 

National  Association  for  Feeble-minded,  43,  238,  242 

Nature -study,  204,  208 

Nerve-storms,  152 

Nervous  action,  abnormality  of,  109-10 


280       MENTALLY  DEFICIENT  CHILDREN 

Neurotic  (primarily),  63,  64,  118-9 

Nomenclature,  n 

Norway,  provision  in,  37 

Nutritional  defect  (glandular),  77,  82  (general),  no 

Object-lessons,  204 
Objections  to  training,  242-3 
Occupations,  207-15 
Operations  on  defectives,  183-4 
Optic  changes  in  maculae: 

In  amaurotic  family  idiocy,  76 

In  central  degeneration,  77 
Organotherapy,  180 
Outdoor  occupation  in  epilepsy,  181 
Overpressure  in  education,  103 
Oxycephaly,  73-4,  81,  107,  118 

Palate,  anomalies  of,  12,  108,  168 

Paralytic  cases: 

Birth  palsies,  72,  101,  126-7 

Complications  of  primary  amentia,  64 

Diplegia,  129;  Hemiplegia,  107,  129;  Paraplegia,  129 

Infantile  (polioencephalo-myelitis) ,  130 

Juvenile  general  paralysis,  71,  142-6 

Parental  intemperance,  96-9 

Parturitional  difficulties,  72 

Pathological  classification,  51-82 

Peg-board  (school  appliance),  189,  192 

Permanent  improvement  (cases),  227,  236 
supervision,  need  of,  219,  229-30 

Phthisical  family  history,  96 

Physical  and  mental  defect,  correlation  of,  1 3 

Physiological  education,  3 

Pictures  in  education,  196 

Pituitary  gland  abnormalities,  67,  80 

Porencephalus,  55,  73 

Post-febrile  cases,  73,  81,  103,  129-30 

Premature  birth,  102 

Primary  amentia.     See  Amentia 

Prognosis,  general,  114-16 

special  types,   118,   119,  123,   124,   126,  127,   129-32, 
141 

Provision  made  in  special  schools,  and  needed,  41 

Psychical  epilepsy,  223 

Pubertal  perversion  of  moral  sense,  149-51 

Puberty  and  adolescence,  psychopathies  of,   142-52 
special  care  at,  175,  223 

Punishments,  217-8. 


INDEX  OF  SUBJECTS  281 

Radiography,  67,  108,.  129,  185 

Reading,  instruction  in,  205,  241 

Recreations,  211-12 

Relief  to  parents  by  training,  234 

Religious  feeling,  225 

Reports : 

Royal  Commission  on  Feeble-minded,  n,  13,  23-7, 
38,  39,  96,  100,  115,  138,  140,  224,  233,  239 

Scientific  study  of  childhood/  12-15 

Chief  Medical  Officer's  Board  of  Education,  41,  156, 

163,  167,  212-14 
Results  and  conclusions,  226-43 
Rewards  and  punishments,  217-8 

Sauvage  de  I'Aveyron,  i 

Scandinavian  countries,  provision  in,  37-8,  40 
Scaphocephalic  cases,  63,  64,'  107-8 
Sclerosis  of  brain,  53,  62 ;  tuberose,  65 
Scotland,  provision  in,  10 

Certified  Institutions,  255 
Scurvy-rickets,  171 
Secondary  amentia.     See  Amentia 
Selection  of  children  for  special  schools,  153-69 
Sense-deprivation,  cases  due  to,  81,  82 
Sensorial  training,  190-7 
Serotherapy,  180-1 
Sexual  erethism,  175 
Shock  (emotional),  74,  82 
Sight,  training  of,  195-6 
Simple  congenital  cases,  63-4 
Size  and  form  boards,  192-3 
Skiagrams  (radiograms),  108 
Skin,  affections  of,  183 

hygiene  of,  172 
Slavering,  repression  of,  173 
Smell,  training  of,  196 
Spain,  provision  in,  38 
Speaking  exercises,  260-1 
Special  brain  areas,  defects  of,  54-8 

classes  and  schools,  17,  37-46 

instruction,  35-50,  239-40 
Speech,  disorders  of,  197-202 

instruction  in,  197-9 
Stammering  and  stuttering,  199 
Sterilization,  221-2 
Stigmata  of  degeneration,  63-4 
Surgical  treatment,  183-5 
Switzerland,  statistical  inquiry  in,  16,  17 
Syphilis,     See  Inherited  Syphilis 


282      MENTALLY  DEFICIENT  CHILDREN 


Syphilitic  cases,  70-2,  93-5,  125-6,  142-6 
lesions  in  hydrocephalus,  61 

Tactile  function,  training  of,  191-4 
Taste  and  smell,  training  of,  196 
Tests  of  intelligence,  111-4 

Binet-Simon,  116,  157-60,  163-165 
Thymus  aplasia,  80 
Thyroid  gland,  abnormalities  of,  79,  80 

treatment,  132,  182 
Timetables,  specimen,  213-4,  262-3 
Toxic  cases,  75,  82,  91,  93,  130 
Training,  educational,  186-206 

Industrial  (and  recreation),  207-215 

Moral,  216-225 
Treatment,  170-85 

General,  171-76 

Medical,  176-83 

Surgical,  183-5 

Traumatic  cases,  73,  81,  103,  129,  141 
Tubercular  predisposition,  96,  129,  176-7 

mortality,  176 

United  States  of  America: 
Provision  in,  4-7 
Institutions,  list  of,  256-9 
Royal  Commissioners'  visit  to,  25 
Results  recorded,  223,  232-4 

Urinary  troubles,  I72:3 

Volitional  weakness,  216 

Wassermann  reaction,  61,  70,  77,  94-5 
Wood-carving  by  athetotic  patient,  127 
Word-blindness  and  word-deafness,  56-8 
Writing,  instruction  in,  205 

X-ray  examinations,  67,  108,  129,  185 


INDEX  OF  NAMES 


ALZHEIMER,  Dr.,  126 
Andriezen,  W.  L.,  180 

Babonneix,  M.  L.,  62 
Barlow,  Sir  T.,  171 
Barr,  Martin,  6,  138,  224 
Batten,  F.  E.,  71,  72 
Beach,  Fletcher,  51,  63,  83, 

101 

Beard,  J.,  91 
Bernheim-Karrer,  Dr.,  62 
Bickmore,  A.,  209 
Binet,  A.,  136 
Blandford,  G.  F.,  136-8 
Bollaan,  Dr.,  101 
Bolton,  J.  S.,  51,  52-3,  147 
Bourneville,  Dr.,  51,  80 
Burden,  Rev.  H.  N.,  44-5 
Burgwin,  Mrs.,  18,  40,  215 

Caldecott,  C.,  84 
Carson,  J.  C.,  5 
Chance,  Sir  W.,  21 
Clouston,  SirT.,  125,  141-5 
Cobb,  O.  H.,  6 
Conolly,  J.,  4 
Crichton-Browne,   Sir  J.,  96, 

100 

Crile,  G.  W.,  75 
Cunningham,  Professor  D.  J., 

60 
Gushing,  Harvey,  67 

Dahl,  Ludwig,  84 

Dean,  H.  R.,  70 

Dendy,  Miss  M.,  44,  138-9 

Donkin,  Sir  B.,  94 

Doren,  G.  A.,  6 

Drummond,  W.  B.,  136,  160 


283 


Elderton,  Ethel  M.,  98 
Ellis,  Havelock,  138 
Emerick,  E.  J.,  6 
Esquirol,  E.,  i 

Fernald,  W.  E.,  39,  160,  232-3 

Finzi,  N.  S.,  108  (opp.) 

Ford,  Rosa,  74 

Fort,  S.  J.,  223 

Fraser,  Kate,  70 

Froebel,  187 

Fromm,  Dr.,  62 

Garrod,  A.  E.,  81,  121 
Gaskell,  S.,  4 
Gilford,  Hastings,  81 
Goddard,    H.    H.,    n,    85-7, 

99,  157-60 

Gordon,  Alfred,  69,  181 
Gordon,  J.    Leslie,    71,    122, 

125,  128 

Gowers,  Sir  W.  R.,  148 
Guggenbiihl,  Dr.,  3 
Guthrie,    Leonard,    57,    121, 

123,  200 

Hammarberg,  Karl,  51 
Herter,  C.,  80 
Hinshelwood,  J.,  56 
Holman,  H.,  3 
Horsley,  Sir  V.,  182 
Howe,  S.  G.,  5-6 

Ireland,  W.  W.,  51 
Itard,  Dr.,  i 

Johnston,  G.  C.,  67-8 
Jones,  Robert,  184 


284      MENTALLY  DEFICIENT  CHILDREN 


Keller,  Christian,  37 
Kerlin,  Isaac,  6,  224 
Kerr,  Jas-,  56,  166,  219-21 
Kielhorn,  Herr,  36 
*Kingdon,  E.  C.,  76 
Koch,  Dr.,  84 
Kraepelin,  Emil,  147 

Langdon-Down,   J.,  63,   101, 

ii5,  175 
Lange,  Dr.,  62 
Lapage,  C.  P.,  115 
Letchworth,  W.  P.,  138 
Lippestad,  Karl,  37 
Lize,  Dr.,  91 
Locke,  E.  W.,  230 

Macdonald,  A.  C.,  138 

McCallum,  A.  J.,  178 

McGarrison,  R.,  182 

Mendel,  G.,  126 

Mercier,  C.  A.,  138 

Mott,  F.  W.,  70,  71,  77, 93, 126 

Ormond,  A.  W.,  121 

Parsons,  L.,  80 
Pasmore,  E.  S.,  163 
Patry,  73,  74 
Pearson,  Karl,  88,  98 
Pinsent,    Mrs.    Hume,    228, 

240-1 

Plaut,  Dr.,  71 
Potts,   W.  A.,   20,   73-4,   92, 

96-7,  115-6,  141,  237 
Powell,  F.  M.,  7 
Poynton,  F.  J.,  76 

Railton,  J.  C.,  182 
Richards,  J.  B.,  6 
Russell,  J.  S.  Risien,  76 

Sachs,  Dr.,  75 
Saegert,  Dr.,  2 


Sajous,  Dr.,  80 
Saleeby,  C.  W.,  243 
Savage,  Sir  G.  H.,  138 
Schwab,  Rudolf,  17 
Seguin,  E.,  i,  2,  3,  6,  15,  171, 

190 

Seguin,  E.  C.,  179,  181 
Sherlock,  E.  B.,  51,  231-2 
Shuttleworth,  G.  E.,  15,  18, 

59-60,  84,  98,  102,  108,  124, 

182,  188 
Simon,  Th.,  136 
Sims,  G.  R.,  75 
Soethre,  Jacob,  37 
Spratling,  W.  P.,  179 
Still,  G.  F.,  223 
Sutherland,  G.  A.,  122 

Talbot,  Eugene,  138 
Tay,  Waren,  76 
Telford-Smith,  T.,  60,  182 
Thomas,  E.  J.,  56,  58 
Thomson,  John,  66,  79,  122 
Tredgold,  A.  F.,  51,  52,  53, 

62,  84,  85,  96,  99 
Tuke,  D.  Hack,  51 
Turner,  F.  D.,  176 
Turner,  W.  Aldren,  123,  179 
Twining,  W.,  3 

Van  Valkenberg,  C.  T.,  58 
Voght,  H.,  65 
Voisin,  Felix,  i,  2 

Warner,  F.,  12,  14-15/109-10, 

160,  239 

Watson,  H.  Ferguson,  70 
Weinrich,  Dora,  36 
Whetham,  W.  C.  D.,  88 
Wilbur,  H.  B.,  5,  6 
Wilmarth,  A.  W.,  62 
Wintermann,  H.,  36 


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